Course: Units: Course: Units:
Course: Units: Course: Units:
Course: Units: Course: Units:
Course: Units: Course: Units:
TOTAL UNITS:
ŽƌiŶŝƚŝĂůs
or initials
: After completing this form, you must meet with a counselor. If you are currently in classes, your counselor
may require progress reports filled out by your instructors.
Complete the top half of this form and email to your counselor before or during your Zoom or phone appointment.
You will receive an email regarding your reinstatement decision and your registration date will appear in WebSmart.
Name: _________________________________________________________ CSM ID#: __________________________
@my.smccd.edu
How many hours a week do you work?
Telephone: ( ) CSM Email:
_______
What happened? What will you do dierently?List factors that led to dismissal status and changes you will make if reinstated.
Last name First name
April 2020
Counselor: ____________________________________ Date: ________________ GPA _________ Progress _________
Discussed Course Repetition/Grade Alleviation Discussed Academic Renewal Policy Previously reinstated?
Counselor’s advice:
OnTRAC Coordinator or Dean of Counseling
_________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________
___________________
Office of Counseling,
Advising & Matriculation
Major, transfer, career, etc.
G #
TOTAL UNITS:
Do not use when planning spring
What is your Educational Goal?
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit