This petition may be used to request an exception to certain deadlines or procedures due to the existence of verifiable
extenuating circumstances. Only one request may be submitted per petition. Students are responsible for providing the
required personal statement and documentation. Failure to provide both will result in the petition being denied. You will
be notified of the outcome via the email you indicate on this form.
EXTENUATING CIRCUMSTANCES: are verifiable cases of accident, illness or other circumstances beyond the control of
the student. Acceptable forms of documentation include doctor’s notes; proof of hospitalization or acting as a
relative’s caregiver; police reports of accident, etc. Documentation must show that circumstances interfered with a
student’s ability to successfully complete the class or drop it by the deadline.
________________________________________________________________ _______________________________
NAME LANCER ID #
____________________________________________________________________________ __________________
ADDRESS CITY STATE ZIP DATE OF BIRTH
_________________ ________________________ _______________________________________
COURSE ID TERM/YEAR EMAIL
_______________________________________
PHONE NUMBER
INSTRUCTIONS
• Check only one box per petition
• Attach the required documentation (not required for additional units, anti-requisite override)
• Attach your personal statement – see below for details*
I AM PETITIONING FOR THE FOLLOWING EXCEPTION:
___ Approval for________ additional units in excess of maximum units allowed. (Required explanation and list of
courses)
___ Grade change to “W” or Late Withdrawal - Provide all of the following:
• Personal statement explaining circumstances that prevented you from dropping the class by the deadline
• Verifiable documentation of extenuating circumstances to support your personal statement
___ Late Add (Signed add slip with first date of attendance from instructor required)
• Provide your personal statement explaining what prevented you from adding the class on time.
___ Anti-Requisite Override
___ Other (Typed explanation required, documentation of circumstances may be required)
___________________________________________________________
Student Signature Today’s Date
OFFICE USE ONLY
_____ Approved _____ Denied
Reason for denial: __________________________________________________________________________________
___________ ____________ ____________ ____________ ________________ _____________
Approved By Date Recorded By Date Response By Date
PASADENA CITY COLLEGE
PETITION DUE TO SPECIAL CIRCUMSTANCES
ADM385 1/16
