Program Withdrawal / Deferral Form
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Date: ___________________
Full Name: _______________________________________ Student ID: ___________________
E-Mail Address: ________________________________ Phone Number: ___________________
Program: ________________________________ Location: ______________________________
I am planning to: Withdraw Defer to _______________________ (term and year)
Reason: _______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you notified your program of your intent to withdraw/defer? Yes No
Do you understand you may still owe fees and/or tuition amounts according
to the rules and policies of your program? Yes No
Please note that you will be charged in accordance with the established Study Abroad Center
policy. Students who withdraw/defer their participation after April 15th for summer and fall terms
or November 15th for spring term will not be refunded the $200 Study Abroad Registration Fee.
___________________________________
Student’s Full Name
___________________________________ ___________________________________
Student’s Signature Lisa Loberg, Director of Study Abroad
60 W Olsen Road #2475, Thousand Oaks, CA 91360
p: 805.493.3750 | studyabroad@callutheran.edu | www.callutheran.edu/studyabroad
