Paul D. Camp Community College – Administrative Withdrawal Request

Administrative Withdrawal Request – Extenuating Circumstances

Home
Forms
Program Maps

Complete the form below. Select one reason for your request and attach or note any supporting documentation. Once you've completed the form, click the Print to PDF button at the bottom of the form. Save it as a PDF to your computer and submit it to the appropriate college office.

* Indicates a required field.

Purpose: For students requesting withdrawal due to significant extenuating circumstances. Approval is subject to applicable college/VCCS policies and review.

Student Information

Student Name *

Student ID *

Phone *

College Email *

Term

Fall Spring Summer

Program of Study *

Withdrawal Request

Withdraw from all courses Withdraw from specific course(s)

Course(s) / Section(s)

Requested Effective Date *

Reason for Request (check one) *

Transfer to another college/school Relocation to another city/state Illness, injury, hospitalization, or medical circumstance Death or serious illness in the family Motor vehicle accident Military service/deployment Significant family/personal emergency Other:

Brief Explanation *

Supporting Documentation

Attached Pending Not Required

Type: Transfer/Relocation Medical Accident/Police Other:

Student Acknowledgment

I certify that the information provided is accurate. I understand submission does not guarantee approval and that withdrawal may affect my academic record, financial aid, tuition balance, satisfactory academic progress, or other benefits.

Student Signature:

Sign here

Signature required

Date:

Dean of Student Services or Designee

Signature of Dean of Student Services or Designee

For College Use Only

Date Received

Effective Withdrawal Date

Last Date of Attendance

Approved Denied Additional Documentation Required Referred for Review

Comments

Reviewed By

Title

Date

SIS Updated Financial Aid Review Business Office Review

When the print dialog opens, choose Save as PDF as the destination.