Updated 4/12/2019
Withdrawal from University Form
For detailed withdrawal instructions, please see https://www.clarke.edu/academics/academic-
resources/withdrawal-process. After completing this form, please complete the Clarke University Exit Survey.
Undergraduate Graduate Major/Program_____________________________________
First Name___________________________ Middle Name_______________ Last Name___________________________
Date of Birth_________ Last date of class attendance, if withdrawing during semester:_____________________
Non-Clarke Email _________________________________ Cell Phone Number _________________________________
Term of Withdrawal*:
Summer Year______
*For students withdrawing between semesters, please select the term following the last term enrolled
Do you plan to return to the university?
If yes, when is your anticipated term of return? _____________
Primary Reason for leaving Clarke: (please check only one box below)
o Academic
o Career
o Financial
o Health/Medical
o Military Assignment
o Permanent Disability
o Personal/Family
o Transferring to another
o Program was not a
good fit
o Other: ______________
Student Statement of Understanding: I understand that by signing and submitting this form, I will
be withdrawn from all classes for which I am enrolled for the term I have specified above. I
understand that I am responsible for tuition and fees assessed according to the university’s refund
policy. I understand that my withdrawing from the University will affect my eligibility to remain in
student housing and to use campus facilities. I understand that my current and future financial aid
awards will be affected and I may be liable for tuition owed as a result of the return of financial ai
nds. Note: Non-U.S. citizens who withdraw from the University may jeopardize their immigration
status and their ability to remain in the United States.
Student Signature______________________________________________________________________ Date________
Signature of Academic Advisor,
Graduate Director, or Department Chair*________________________________________________ Date________
*Signature may be scanned or email from advisor/graduate director/department chair to
registrar@clarke.edu will be accepted in lieu of signature.
Clarke University Registrar’s Office, 201 Haas Administration