Student Withdrawal Request

STUDENT WITHDRAWAL REQUEST

Student Information

Date of Birth:

Current Address:

Withdrawal Details

Effective date of withdrawal:

Last date of attendance or academically related activity (if different):

Withdrawal type: Voluntary withdrawal from all courses Withdrawal from specific courses

Reason for Withdrawal

Medical reasons (documentation may be required)
Transfer to another institution
Academic difficulty
Financial reasons
Disciplinary separation or administrative action
Other (explain below)

Parent / Guardian (if student is a minor)

Is the student under 18 at the time of withdrawal? Yes, student is a minor

Financial and Administrative Acknowledgments

By submitting this form I acknowledge and agree to the following administrative statements (initial each):

Initials: I have read and accept the institution's tuition and refund policy; financial obligations incurred prior to the effective withdrawal date remain payable.

Initials: I will return all institutional property (library materials, equipment, keys) by the date specified by the institution.

Initials: I understand that official transcripts, diplomas, and registration privileges may be withheld until all financial and property obligations are satisfied.

Forwarding and Emergency Contact

Certification and Authorization

I certify that the information provided on this Student Withdrawal Request is true and complete to the best of my knowledge. I authorize the institution to process this withdrawal request according to applicable academic and financial policies. I understand that processing may result in changes to my academic record and financial account. I agree to cooperate with any follow-up required by the Registrar or Student Accounts Office.

Administrative Use Only

Processed by: Department:

Date processed:

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