Fillable Retroactive Withdrawal Procedure

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Retroactive Withdrawal Procedure

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Retroactive Withdrawal Procedure
A student who wishes to leave the University without completing the semester/term is expected to withdraw
during the current semester and/or term for which he or she is enrolled. Requests to withdraw after the
semester and/or term is over are considered only if the student was unable to withdraw. Examples of being
unable to withdraw include, but are not limited to hospitalization, military deployment, or being debilitated
by mental illness. In these cases, students must submit compelling documentation. If the documentation is
considered sufcient, the Vice President for Student Life or her designee will contact each faculty member on the
student’s schedule. Each faculty member will be asked for their approval of a retroactive withdrawal. Please
note, a faculty member is not given condential medical information, but is asked for approval of a retroactive
withdrawal for medical reasons. Retroactive withdrawals will not be considered past the next semester or term.
Today’s Date
From what semester are you requesting to be retroactively withdrawn?
Name: Student ID
Mailing Address
Telephone Number where you can be reached during the day:
Email Address:
I. Medical Condition
What was your diagnosis? Please give a brief description of your condition and state why this condition
interfered with your academic performance and or class attendance at the time. Attach additional pages and
documentation to support your condition.
On approximately what date did your medical condition begin to interfere with your class attendance or
academic performance during the semester that you are requesting to retroactively be withdrawn?
On approximately what date did you stop going to class during the semester or did you attend until the last
day?
Did you complete the coursework in any of your classes during the semester and/or term?
Were you under medical care by a healthcare provider at TWU for this condition during the semester and/or
term or have you even been seen by a TWU healthcare provider for this condition?
Were you under medical care by a healthcare provider outside of TWU for this condition during the
semester and/or term in question?
If yes, you must include documentation that includes the dates that you were seen for medical care during
the semester and/or term including a diagnosis and or a description of your symptoms, and or a brief
summary in support of your request from your outside healthcare provider.
Financial Aid
Did you receive nancial aid for the semester and/or term from which you are requesting to be withdrawn?
Do you have any existing loans with TWU?
Were you attending TWU on a scholarship?
If yes to any of these last three questions, we strongly recommend that you contact the Ofce of Financial
Aid prior to withdrawing to obtain information regarding any nancial penalties that might occur.
A retroactive withdrawal may result in the loss of eligibility for part or all of any federal or state nancial aid
paid to you earlier in the semester and/or term. Any nancial aid funds for which you are determined to be
ineligible would have to be repaid by you to the Bursar’s Ofce within 60 days.
I understand that the Ofce of Student Life may contact my department and/or professors to verify my
information.
Signature of Student Date
I understand that it is my responsibility to contact the Ofce of Financial Aid prior to submitting my ap-
plication to the Ofce of Student Life in order to obtain information with regard to penalties that might
occur as a result of my request for a retroactive withdrawal for medical reasons.
Signature of Student Date
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
No
No
No
No
No
No
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International Ofce
Were you registered through the International Ofce during the semester from which you are requesting a
retroactive withdrawal for medical reasons?
If yes, you must get permission from the International Ofce to pursue this retroactive withdrawal for
medical reasons. This is to ensure that you will remain in good standing as an international student at TWU
Executive Director of Civility & Community Standards
Before the Vice President for Student Life can consider your application, we must conrm that
there are no past or present disciplinary matters that might be relevant in determining the appropriateness
of the retroactive withdrawal for medical reasons. Accordingly, a student must give his or her consent to
the Executive Director of Civility & Community Standards to provide to the Vice President for Student Life
any and all information regarding disciplinary matters, including ongoing investigation.
Procedure
Please submit your completed application to Vice President for Student Life in the Student Union,
Room 206, fax (940) 898-3629
After submitting your application, it will take from 10 to 14 working days before you are notied, via email, by
the Vice President for Student Life of a decision.
I hereby request and authorize the Executive Director of Civiltiy & Community Standards at Texas
Woman’s University or any of their representatives to release any information, documents and or
records related to any discipline matters pertaining to me.
Signature of Student Date
I understand that it is my responsibility to contact the International Ofce prior to submitting my
application to the Ofce of Student Life in order to obtain information with regard to penalties that
might occur as a result of my request for a retroactive withdrawal for medical reasons.
Signature of Student Date
Ye s No
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Retroactive Withdrawal Procedure

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Completed 5 January 2020

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