Hudson County Community College
Special Circumstances for Withdra wal
Early College Students Only
Course ID Ex. ENG - 101 Course Title Ex. College Composition I
When students register for courses at Hudson County County College, they enter into an agreement with the institution that
acknowledges responsibility for meeting deadlines and financial obligations. The institution is also sensitive to the fact that students
may face extenuating circumstances beyond their control. For this reason, the college offers students the ability to petition for a
withdrawal after the deadline or a grade change (“F” to “W”), provided they can present appropriate documentation.
Please review the list of eligible circumstances and acceptable supporting documents below to determine if you are eligible. Only
petitions with acceptable documentation will be considered for up to one year after the circumstance. Students who would also like to
request tuition adjustment must indicate this by checking the box below. Grade changes and tuition adjustments are considered
separately. All decisions are final and no appeals will be accepted.
Student First Name: ______________________________ Student Last Name: ________________________________
Student HCCC ID#: _______________________________ Phone Number: ___________________________________
Email Address: __________________________________
Street Address: __________________________________ City: _____________________ State: _____ Zip: _______
Please select the reason for the special circumstance request:
Medical emergency: Student must submit a physician’s certification on official letterhead and/or hospitalization records.
Documentation should include dates of treatment. Admittance date will serve as date of withdrawal.
Passing of an immediate family member (spouse, child, mother, father, sister, brother, grandparent) that impacts student’s
ability to return. An obituary along with proof of relation must be submitted.
Military orders that impacts student’s ability to return. Students must submit a copy of military orders.
Filed for official bankruptcy where HCCC is named.
Personal matters: Students must submit a written statement of the problem and verification from care team member
(minister, social worker or counselor) that will support your statement.
Please select all that apply:
I am currently enrolled and requesting to withdraw from my course(s) prior to receiving a failing grade, since the withdrawal
deadline for this course has passed.
petitioning course will be considered.
I am requesting a grade change from “F” to “W.” Only requests submitted within a year of the start of the semester for the
I would also like to be considered for a tuition adjustment. Please keep in mind that if you receive a refund check, a tuition
adjustment may require that you return the refund.
Course Term: ____ Fall ____ Spring ____ Summer I or II Course Term Year: _______
Please list all courses that you are requesting a special circumstances withdrawal for:
Revised 10/31/2019
Personal Statement
Please describe why you are requesting a special circumstance for withdrawal:
Special Notes:
√All correspondence will be sent through an HCCC email.
√ The College uses the date of the emergency as the withdrawal date, not the date of last attendance.
√ Please attach all supporting documentation.
Student Signature: _________________________________________ Date: _________________
Withdrawal Approved
_________Withdrawal Denied
__________ Tuition Adjustment Approved _________Tuition Adjustment Denied
Signature: ___________________________________ Date: ______________________________
Title: ____________________________________