Student Withdrawal Form

This form is designated to document student withdrawals, who are students that stop attending after the drop deadline (Last day to withdraw form a course without academic penalty) and will receive a grade of “W”. Please review the academic calendar for academic penalty deadlines.

As the person completing this form, I recognize that:

The absences for the students constitute unsatisfactory progress as defined by the syllabus for this course.
I understand the appropriate grade (W, F, or U) will automatically be assigned based on the Academic Calendar deadlines. Once assigned, a grade of “W” cannot be removed from an academic record.

Student Information*

First Name	Last Name	SIS Identification #	Last Date of Attendance

If more than one student, please add a row +

Semester*

Please select one of the following sessions:*

Year*

Course Information

Class Number Subject Catalog Number Class Section

Which Academic Dean should receive this for approval?*

Faculty Name*

First Last

Faculty Signature*

Your Email*

A confirmation will be sent to this email address.