Student Name: Student ID: 900_______________________
Student Email: (only)
Student Phone #: _____________________
Course Name & Title: CRN:
Course Name & Title: CRN:
Course Name & Title: CRN:
Course Name & Title: CRN:
Justification for Request:
Job transfer outside the geographical region
Illness in the family where the student is the
primary caregiver
An incarcerated student in a CA State Prison or
County Jail is released from custody or
involuntarily transferred before the end of term
The student is the subject of an immigration action
Death of an immediate family member
Chronic or acute illness
Verifiable accidents
Natural disaster directly affecting the student
Other reason beyond the student’s control (must include
personal statement explaining request AND verifiable
documentation of extenuating circumstances)
If supporting documentation is not provided, petition cannot be approved (Check all to acknowledge)
I have attached verifiable medical, legal, or other appropriate documentation, dated for the term in question, that
supports the claim that completion of the course is impossible due to reasons beyond my control.
I have attached my personal statement explaining my request (ONLY required if you have checked “Other” above)
I understand that I should consult the financial aid office regarding the impact an Excused Withdrawal may have on my
financial aid, depending on my circumstance, prior to submitting this request.
I certify that all information provided is accurate and complete to the best of my knowledge and any false information will
be cause for denial.
Student Signature: Date:
Registrar Signature:
Date: ______________________
Rev 6/19
Excused Withdrawal Request
Spring 20____ Summer 20____
Fall 20____
Justification for Request & Documentation
POLICY: Per VCCCD AP 4230, the EW symbol may be requested by the student and used to denote withdrawal. Excused Withdrawal
(EW) shall not be counted in progress probation or dismissal calculations nor shall it be counted towards the permitted number of
withdrawals or counted as an enrollment attempt. An EW is acceptable when a student withdraws from a course due to reasons
beyond their control and must be supported by verifiable documentation. Effective on or after January 2018, grade changes may be
requested by the student no more than three (3) years after the term in which the grade was awarded, per VCCCD AP 4231. Grade
changes for terms prior to January 2018 cannot be considered. A change of academic grade to Excused Withdrawal (EW) will be
recorded only after this petition has been completed, signed by the student, determined to meet the requirements of the policies of
the VCCCD, and approved by the Registrar. Students applying for an EW will not be eligible for a refund.
Registrar Approval Approved Denied
(Initial): ________ Date: _____________ Student Notified (Initial): __________________ Date: ___
Notified* (Initial): __________________Date: ______________ *Faculty will be notified when a letter grade is changed to an EW.