Rev. 10/30/18
SINGLE CLASS WITHDRAWAL FORM
A current student may request to withdraw from a single class by completing Section 1 of this form after the add/drop deadline
has passed. The student must receive authorization from the appropriate School Official as noted in Section 2 of this form. A
student who wishes to withdraw from all classes in a term must complete a Request for Temporary or Permanent Withdrawal.
Section 1
Name: _______________________________________________________________________________________
(Last name) (First name) (Middle name)
Program: _____________________________________________________________________________________
MCW Email Address: __________________________________________________________________________
Term for which you are requesting the class withdrawal(s): Fall Spring Summer (Graduate School only)
Class(es) for which you would like to withdraw:
(i.e. Subject: PUBH, Course Number: 18203, CRN: 01234)
Subject: ______________ Course Number: ______________ CRN - Course Reference Number: ______________
Last Date of Class Attendance (MM/DD/YYYY): ______________ Date will be confirmed with course director.
Subject: ______________ Course Number: ______________ CRN - Course Reference Number: ______________
Last Date of Class Attendance (MM/DD/YYYY): ______________ Date will be confirmed with course director.
Subject: ______________ Course Number: ______________ CRN - Course Reference Number: ______________
Last Date of Class Attendance (MM/DD/YYYY): ______________ Date will be confirmed with course director.
I hereby request to withdraw from the class(es) referenced above. I understand that I will receive a final grade of W - Withdrawn
and no credit, and that the class(es) do not count toward my enrollment status (e.g. full-time, half-time).
Student Signature: _______________________________________________________ Date: ________________
Section 2
School Officials:
• Graduate School: Angie Backus, Director of Enrollment & Student Affairs, abackus@mcw.edu /414-955-5670
or Neil Hogg, Associate Dean, nhogg@mcw.edu/414-955-4012
• Master of Science in Anesthesia Program: Michael Stout, Program Director; contact Abby Haak, ahaak@mcw.edu /414-
955-5608
• Medical School: Dr. Carol Ping Tsao, Associate Dean for Student Affairs, ctsao@mcw.edu /414-955-8256
• School of Pharmacy: Joel Spiess, Program Manager for Academic Affairs, jspiess@mcw.edu /414-955-2858
Note: All international students in F-1 immigration status must consult Angie Backus at abackus@mcw.edu.
I approve/deny the student’s request as noted above.
Required School Official Signature: Date: ________________
ALL COMPLETED FORMS MUST BE IMMEDIATELY RETURNED BY THE SCHOOL OFFICIAL TO:
Office of the Registrar, M3200, 8701 Watertown Plank Road, Milwaukee, WI 53226 · acadreg@mcw.edu /414-955-8733
Registrar Signature: _____________________________________________________ Date: ________________
