Fillable Student Chec klist Withdrawal Exception Request: Please the (Cuyahoga Community College District)

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Student Chec klist Withdrawal Exception Request: Please the (Cuyahoga Community College District)

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Withdrawal Exception Request
___
Victim of a Crime or Catastrophic Event:
a. Police report with dates and times
b. Explanation of how this made student miss the withdrawal deadline
c. Explanation of impact on coursework and reasons for inability to complete class(es)
Student Chec
klist
Student Name: S#: S Phone #
Withdrawal Exception Request: Please the appropriate circumstance pertinent to your
situation along with required documentation below.
Withdrawal “W” only (Accepted after the last published date to withdraw with a “W” grade)
Caregiver: (unexpected caregiver responsibilities)
a. Medical form signed by a licensed physician
b. Legal documentation (i.e. power of attorney)
c. FMLA leave documentation
d. Proof of impact on daily life and activities
Extreme Medical Conditions: (i.e. documented hospitalizations, inability to return to work,
F
M
L
A leave)
a. Completed medical form signed by an external, licensed physician
Work Changes: (documented work shift changes that conflict with class schedule and are beyond
th
e
student’s control)
a. Letter on company letterhead from your supervisor
___ Incarceration:
a. Date of incarceration
b. Court documentation
c. Release information
___ Death of Immediate Family member: (spouse, child, parent, siblings, legal guardian,
grandparent or legal court advocate)
a. Obituary or Death Certificate
b. Documentation proving relationship
___ Homeless:
a. A letter on letterhead from a homeless shelter, social worker, clergy member with church affiliation, or other
professional support org.
Non-Acceptable Reasons for a Withdrawal Exception Petition
1. Loss of transportation, unless due to a motor vehicle accident
2. Selective course petitions, unless there is a specific reason for a specific course (PE, typing, etc.)
3. Incomplete documentation
4. Past submission deadline – decision of the committee is final and cannot be appealed
5. Submission deadline is defined as 30 days after the academic semester for which you are petitioning (Subject to change
each academic year).
6. Submissions must be date stamped by EC Rep, either in-person or, if received via email, by email date
Required Withdrawal Exception Forms You must submit the following forms:
Checklist Financial Aid Advising Form
Petition and Medical Documentation Instructor Verification Form
Written statement (1 page max) of the extenuating circumstances for exception to the posted withdrawal dates and
what resolution is being requested.
Student Confirmation - Initial all line items below and then sign.
My extenuating circumstances prevented me from following the College’s Withdrawal policy:
http://www.tri-c.edu/catalog/Documents/2013-14-35_AcademicInformation.pdf
I understand that submission of a Withdrawal Exception Petition does not guarantee approval.
I understand that I may be required to submit additional documentation if my current documentation does not
substantiate my request. I will be given 30 days from the review date to provide any additional documentation
before the petition will be automatically denied by the committee.
I understand that if I received federal financial aid, I must meet with a financial aid advisor prior to submitting
my Withdrawal Exception Petition.
I understand that incomplete petitions will be automatically denied and will not be reviewed by the
Withdrawal Exception Committee.
I understand if the petition is approved and I am withdrawn from all my courses listed on the petition, my
financial aid, graduation date and/or registration may be affected.
I understand that if the petition is approved and grades have been awarded, each instructor has the final
decision to approve or deny the change of grade.
I understand if the withdrawal petition is denied by the withdrawal committee, I remain responsible for my
courses and will receive the grade my instructors submit at the end of the term along with any financial
repercussion this may cause.
I understand that conditions approved under past withdrawal petitions may not be approved
again
. I
understand that the Withdrawal Exception Committee meets monthly to review petitions. I will receive
written notification of the committee’s decision.
I understand all decisions made by the Withdrawal Exception Committee are final—and are not subject to an
appeal.
Student Signature Email Date
Withdrawal Exception Request
Petition and Medical Documentation
Fo
rm
Student ID Number: S Date of Birth:
Name:
Address:
City: State: Zip:
Home Phone :( )_ Cell Phone :( )_
Dear (Licensed Physician):
Because of my illness/injury I am petitioning Cuyahoga Community College to withdraw from the classes that
I had attended or have been attending during Term
The college requires a Licensed Physician documentation of my illness/injury. I give you permission to
complete this form. Please complete and return to me at the above address. Thank you in advance for your
time and effort in this matter.
Signature: Date:
To be completed by Licensed Physician
Diagnosis_
List Specific Dates that you saw this student for the illness during the time period specified above:
mm/dd/yr
List Specific Dates of Hospitalization (If Applicable): mm/dd/yr
The Illness/Injury prevented this student from attending class(es):
From: mm/dd/yr To: mm/dd/yr
Additional
Comments:
Physician’s Printed Name_
Physician’s Signature
Address_
Phone No. Date
Withdrawal Exception Request
Financial Aid Advising Impact Information Sheet
Students withdrawing from all courses for the term, whether through the Withdrawal Exception
Process or on their own should be aware of how this may affect not only current financial aid
standing, but also future financial aid eligibility. Below is a list of items students should consider.
Return to Title IV – Federal Financial Aid funds are considered Title IV funding. When a student completely
withdraws from a term, either self‐initiated or via the Withdrawal Exception process, the school is required to
complete a calculation to determine the amount of earned and unearned financial aid. Any unearned financial
aid must be returned to the U.S. Dept. of Education on behalf of the student. This calculation is completed
within 30 days of a student completely withdrawing or the institution becoming aware of the students
withdrawal.
Overpayment – Students are awarded financial aid based on financial need and enrollment status. If a
student changes enrollment status, it is possible for the student to have received too much financial aid,
causing an overpayment. Aside from funds owed to the college an overpayment of financial aid is due back to
the U.S. Dept. of Education by the student. An overpayment may result in a student not being able to receive
Federal Financial Aid funds at any institution until this balance is paid, or successful payment arrangements
have been reached.
Transferring/Using Remaining Funds – Any funds applied to a student account will decrease a student’s
financial aid eligibility at another institution during the same award year. This may result in a student having
less financial aid eligibility at their new school due to what was awarded/paid at the previous institution.
Standards of Satisfactory Academic Progress (SAP) – Federal Financial Aid Regulations state that a student
must be completing 2/3
rd
( 67%) of their enrollment, and maintain a GPA eligible to graduate (2.0 or higher at
Cuyahoga Community College). Students failing to meet these standards are subject to losing financial aid
eligibility for a term or longer and may need to appeal to try to regain their financial aid eligibility. A students
SAP status is non‐transferrable, meaning that a student’s status at Cuyahoga Community College does not
affect their eligibility at another institution.
Subsidized Loan 150% Rule –Federal Financial Aid Regulations regarding loans state that a student will
lose their eligibility to receive a Federal Direct Subsidized Loan once they have exceeded 150% of their
program’s published length of time. Students enrolled in a published two year program are allotted three
years to complete before they are no longer eligible to receive a subsidized loan. This is applied to new
borrowers as of 7/1/2013 (A new borrower is considered anyone that had a zero outstanding federal loan
balance as of 7/1/2013, or at the time of the loan).
Pell Grant Lifetime Limit –Federal Financial Aid Regulations have been put in place regarding Pell Grant.
Once a student has received the equivalent of 600% they are no longer eligible to receive the Pell Grant. This
is based on the number of semesters enrolled and enrollment status during which Pell Grant was disbursed.
For example, if a student attends full time status during fall semester, and used Pell, they would have used
50%. During the spring semester, the student attends full time again, and uses Pell. The student’s Pell usage
for the year would be 100%, and the student would then have 500% remaining.
Direct Loan Aggregate Limits – In addition to the annual loan limits for students, Federal Financial Aid
Regulations stipulate that a student may receive a total of $57,500 (dependent students are limited to
$31,000. Up to $23,000 can be subsidized, depending on eligibility. Independent borrowers may utilize the
full $57,500) total during their undergraduate degree. If a student reaches this level prior to completing their
degree program, and wish to continue borrowing, payments may have to be made toward the loan aggregate
amount, before the student is eligible to borrow again.
Withdrawal Exception Request
Financial Aid Advising Form
Petition for:
(term)
(year)
Tri‐C ID:
S
Student Name:
(PLEASE PRINT)
LAST
First
MI
Home Phone: Cell Phone:
Students who receive financial aid for the term for which they are requesting a withdrawal exception
should be aware that submission of this petition may require an adjustment to financial assistance and
may create a balance due to Cuyahoga Community College and/or to the U.S. Department of Education,
regardless of the committee’s decision. Students having never attended their course(s) are subject to
having financial aid adjusted based on actual enrollment for the term, which may cause a balance.
Withdrawing may impact your financial aid in two ways:
1. If you withdraw from classes during the semester, money may be returned on your behalf to the
U.S. Dept. of Education. Federal financial aid regulations require that unearned financial aid
funds must be returned to the U.S. Dept. of Education. Students may not appeal the return as it
is based on federal financial aid regulations.
2. Withdrawing may put you at risk for not meeting the Standards of Satisfactory Academic
Progress.
Financial Impact: Last Date of Attendance: Never attended
Financial Aid received for the term:
Grants $ Loans $
**Estimated amount that will be owed by the student (NOTE: This amount is only an estimate based on
information you provide the Financial Aid Advisor at the time of appointment. The actual amount may be
higher or lower, depending on the documented last date of attendance provided by your instructors or
other departmental representative.)
Grants $ Loans $ (owed to Cuyahoga Community College)
Overpayment Amount $ (Owed to U.S. Dept. of Education – (800)621‐3115)
Student Statement:
I have met with my financial aid advisor on
and understand the impact this
withdrawal may have on my current and future financial aid and Standards of Satisfactory Academic
Progress. I understand that, as a result of this process, I may owe money back to Cuyahoga Community
College and/or to the U.S. Department of Education. Any balance remaining 60 days after the end of
the term are subject to be sent to the Ohio Attorney General’s Office for Collection.
Stude
nt
Signature
Date
Financial Aid Advisor Signature
Date
Withdrawal Exception
Request
Instructor Verification
Form
Pe
t
i
t
io
n
for
(
t
er
m
)
(ye
a
r)
Tri-C
ID:
S
Student
Name:
(PLEASE PRINT) LAST FIRST MI
Home
Phone:
(
_)
Cell
Phone:
(
_)
This form must be completed by each faculty member from whose course a student seeks to withdraw.
To: Faculty
The above-named student has applied for the Withdrawal Exception Petition. The student has been
instructed to contact you, the professor. Please note that your support of this withdrawal does not
guarantee that the student’s request will be granted. Decisions about approving withdrawals are
made by the college, not the individual faculty members. Information from the student’s instructors
about attendance and academic performance at various points throughout the semester is crucial for
the college in considering the student’s petition, but faculty are not asked to make
a
recommendation
about whether the petition should be approved or not. The reasons for requesting
a withdrawal can often be very personal or sensitive. The student does not have to discuss with the
faculty member the reasons for the request for a withdrawal since the faculty member is only being
asked to report to the college about the student’s academic performance and last date of attendance
in the class that semester.
By signing your petition form, your instructor of record indicates that you have informed him/her
that you are petitioning for a late withdrawal.
List all classes for which you are requesting withdrawal (ALL Sections must be completed):
Subject
Area
Course
Number
Section
Number
Credit
Hours
*Last Attended Date
*Required
*Instructor Signature
*Required
ENG
1010
80221
3
09-15-06
Walker
__________
__________
__________
_______
_________________
____________________________
__________
__________
__________
_______
_________________
____________________________
Instructor comments:
Withdrawal Exception Request
Petition Form
(term)
(year)
Tri-C ID:
S
LAST
First
MI
State:
Zip Code:
Petition for:
Student Name:
(PLEASE PRINT)
Street Address:
City:
Home Phone: Cell Phone:
Please submit the completed form to the Campus Enrollment Center. Your request for an exception to the
withdrawal deadlines will not be reviewed without proper documentation. College guidelines state that a student
must submit a Withdrawal Exception no more than 30 days after the academic semester.
List all classes for which you are requesting withdrawal (ALL Sections must be completed):
EX.
Subject
Area
ENG
Course
Number
1010
Section
Number
80221
Credit
Hours
3
Last Attended Date
09-15-06
Instructor
Walker
1.
2.
3.
4.
5.
Military Call-up:
Yes
No
Date of Orders:
(please provide copy)
Statement of Acknowledgement
I hereby certify that the information provided is correct and true to the best of my knowledge. I understand that
submitting fraudulent information or failure to follow specified instructions may interfere with my request.
Student Signature
Date
DO NOT WRITE BELOW THIS LINE – OFFICE USE ONLY
Campus Representative
Date
Approved
Medical Representative
Date
Disapproved
Comments:
Revised 7/16
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Completed 26 July 2020

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