STUDENT APPEAL FORM
(With Late Add/Drop)
Appeals will only be accepted within 2 years from when you took the course for which you are appealing.
PLEASE
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Student Name:
___________________________________________________________________________
Address: ________________________________________________________________________________
City: _____________________________________________ State: ______________ Zip: _____________
Telephone Number:__________________________________ Student ID B# _________________________
Student Email Address: _____________________________________________________________________
Course (s) Appealing: ______________________________________________________________________________
Instructor(s) Name:___________________________________________ Term:________________________
Student Signature:_________________________________________________ Date:___________________________
Please read both sides of t
his form ca
refull
y and
follow the
procedu
res
in
th
e order
th
ey are listed
.
All
appeals
must
be
accompanied by full documentation (i.e. schedule, billing statement, physician’s note, employer letter, etc.) justifying
the student’s request. These procedures
must
be
followed
befo
re an
appeal
may
be
submitted.
Incomplete
appeals
will
be
retu
rned to the student for completion.
There are two types of appeals. Determine which best describes your circumstances (situation) and follow the
procedures for that type of appeal.
I. Academic Appeal Issues with the instructor, classmates, course content and/or delivery, grades, etc.
Complete the appeals process with Steps
1
through
5
.
II.
Administrative Appeal Issues with the administration, registration, late withdrawals due to medical problems, or
other extenuating circumstances (documentation required).
Complete the appeals process with Steps 3 through 5.
1.
Meet with the instructor and attempt to resolve the issue.
Request
Approved
Instructor Signature Date
3.
For all appeals, submit this Student Appeal form with full documentation
attached, to the Campus
Associate Provost or Dean for review.
Request Approved
Request Denied
2.
Meet with the department chair on the same campus.
Department Chair
/
Program
Manager Signature Date
Campus Associate Provost/Dean Date
RESOLUTION:
Request Denied
Request Approved
Request Denied
The Associate Provost/Dean will notify you in writing of his/her decision. If not satisfied with the resolution at step 3, you may request in writing,
through the Associate Provost/ Dean's office, a review by the Associate Provost/Dean’s immediate supervisor. The request must be received within
ten days of student notification of the resolution and must contain additional documentation that is pertinent to the appeal. The decision of the
Provost or supervisor is final.
If you feel that the established procedures were violated, you may request an administrative review by the Vice President of Academic & Student
Affairs/CLO. This is NOT a re-trial of the incident, but a procedural review. The request for administrative review must be made in writing through
the Associate Provost/Dean’s immediate supervisor within five days of receiving notification of the resolution. The decision of the Vice President is
final.
SC-074B R0032619 Green 11x17 dbl sided half fold
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4. I am requesting (be specific):
5. My reason(s) for making this request (be specific):
Attach additional pages if necessary. Consult Student Handbook for additional information.
Inquiries regarding the College’s nondiscrimination
policies may be directed to:
Ms. Darla Ferguson, Chief Equity and Diversity Officer
Cocoa Campus, Building 2, Room 103
1519 Clearlake Road, Cocoa, FL 32922
Phone: 321-433-7080
E-mail: fergusond@easternflorida.edu
OR
Lt. Mark Renkens
Security & Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Rm. 215
3865 North Wickham Road, Melbourne, FL 32935
Phone: 321-433-7180
Fax: 321-433-5026
renkensm@easternflorida.edu
Inquiries regarding veterans’ programs may be
directed to:
Military & Veterans Service Center
Student Services Center/Administration
Building 1, Room 140
3865 N. Wickham Road, Melbourne, FL 32935
Phone 321-433-7880
OR
Military & Veterans Service Center
Ralph M. Williams Student Center,
Building 11, Room 113
1519 Clearlake Road, Cocoa, FL 32922
Phone: 321-433-7880
Eastern Florida State College is dedicated to providing a nondiscriminatory environment which promotes equal access,
equal educational opportunity and equal employment opportunity to all persons regardless of age, race, national origin,
color, ethnicity, genetics, religion, sex, gender preference, pregnancy, disabilities, marital status, veteran status, ancestry or
political affiliation in its programs, activities, or employment.
This form must be submitted to request to add or drop a course by exception after the published last day to drop or add.
Please print legibly.
Term: ____ Fall ____ Spring ____ Summer Year:___________
________________________________________________________________________________________________
Student Name (Print Legibly) Student ID Number
__________________________________________________________________________
____________________________________
Daytime Phone Student Program of Study
_____________________________________________________________________________________________________________________
Student Signature Date
Course(s) to be ADDED to Schedule
Instructors should be able to verify that a student has been attending the course or that the instructor is willing to assist the
student in making up any missed work (or the student has agreed to accept any penalties for missed work) prior to enrollment in
the class. Student must read and sign the back of this form as well.
REASON FOR LATE COURSE ADDITION:__________________________________________________________________________
_________________________________________________________________________________________________________
CRN
COURSE NO. AND
SECTION
(Ex. ENC 1101-70C)
CREDIT/CLOCK
HOURS
STUDENT
ATTENDING
CLASS (Y OR N)
INSTRUCTOR APPROVAL
DEPARTMENT HEAD APPROVAL
Course(s) to be DROPPED from Schedule
If student has attended beyond the end of the drop period, student should withdraw, not drop. Late course drops should only be
approved if student is able to document extenuating circumstances beyond their control. Instructor or Program Manager
signature is required only for students dropping a course in a clock hour or limited access program.
REASON FOR LATE DROP: ____________________________________________________________________________________
__________________________________________________________________________________________________________
CRN
COURSE NO. AND
SECTION
(Ex. ENC 1101-70C)
CREDIT/CLOCK
HOURS
INSTRUCTOR/PROGRAM MANAGER APPROVAL REQUIRED
FOR CLOCK HOUR OR LIMITED ACCESS PROGRAM
DROP STUDENT FROM FUTURE
PROGRAM COURSES?
(Y OR N)
(Y OR N)
(Y OR N)
(Y OR N)
Associate Provost/Dean Complete Below. Approved: _______ YES _______ NO
ASSOCIATE PROVOST/DEAN ________________________________________________________________ Date _______________________
Scan applicable paperwork. Send this form to the Office of the Registrar at Grades@easternflorida.edu Signed form must be
completed and submitted for registration within one week of final approval or it becomes invalid.
Office of the Registrar: Student Notified via: _________ email _________ phone _____________ Other
Processed by: ______________________________________________________________________________ Date ____________________
LATE REGISTRATION ADD/DROP FORM BY EXCEPTION
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REGIS
TRATION and
FINANCIAL RESPONSIBILITY AGREEMENT
Thank you for choosing Eastern Florida State College. In addition to all Eastern Florida State College (EFSC)
academic standards and
policies, I hereby agree to comply with the terms and conditions specified in this
Registration and Financial Responsibility
Agreement in order to enroll for courses at EFSC. I also agree to abide by
rules and regulations described in the EFSC Catalog and
EFSC Student Handbook.
I ackno
wledge that any activity I conduct through EFSC indicates my agreement to the specified terms and
conditions, including my
agreement to be financially responsible to EFSC for payment of all tuition, fees and related
costs of enrollment for classes in which I
am registered whether or not I attend the class.
I understand that course(s) must be dropped before the end of the drop period in order to be eligible for a full
refund. It is my
responsibility to drop my classes as the college will not automatically drop them for me.
I acknowledge that if I withdraw from a course(s) after the end of the drop period, or if I am administratively
withdrawn for non-
attendance or other reasons, I will be responsible for repaying any applicable Bright Futures
Scholarship funds, Federal Title IV
financial aid funds, or any other amount due as a result of the withdrawal. Any
reduction in financial aid based on nonattendance will
result in a balance due to EFSC.
I understand past due student account balance will result in a financial hold, which prevents future registrations as
well as other
services being offered in accordance with college policy. I understand and agree that EFSC will
withhold transcripts, diplomas, and
other services until all outstanding balances have been satisfied in full.
I acknowledge that all outstanding obligations (along with appropriate personal information including social security
number) may be
referred to an outside collection agency and credit reporting bureaus.
I understand that I am responsible to reimburse EFSC the fees of any collection agency, which may be based on a
percentage not to
exceed 33% of the debt, including attorney fees and court costs.
In addition, I agree to allow EFSC and its agents to contact me at any cell phone number that I provide now or use
in the future,
using automated telephone dialing systems, artificial or pre-recorded voice or text messages, or
personal calls regarding my
obligation to repay my debts to the EFSC.
I also authorize EFSC or its agents to contact me via my easternflorida.edu address or an email address that I
provide to EFSC. I
understand that others may be able to review my messages and/or emails related to my debts
sent to or from EFSC including their
contents, which may include information about my debt and its status.
I understand that EFSC uses Titan E-mail, a free student email system, as the official means of communication for
registered
students. Financial Services utilizes this system for notifications regarding student accounts. Students
should maintain and check their
EFSC e-mail accounts regularly.
I understand this agreement shall be construed in accordance with Florida law, and any lawsuit to collect unpaid
fees may be
brought in the appropriate court sitting in Brevard County, Florida, regardless of my domicile at the
time of bringing such action.
I understand by signing this form, I am agreeing to all terms and conditions set forth herein above and agree to the
incorporation of
any other related documents. I enter into this Registration and Responsibility Agreement with full
knowledge of its legal implications
and without coercion and/or promises made to me by the college. I also agree
and acknowledge that prior to agreeing to this
Agreement, I have the right and option to discuss the terms and
conditions herein with a private attorney at my sole expense.
___________________________________________ _________________ B ____________________________
Student Signature Date Student ID Number
SC-074B R051418
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