Late Withdrawal Form - St. Cloud State University

St. Cloud State University
REQUEST FOR LATE WITHDRAWAL
Note: For international students with F-1 and J-1 status, withdrawals from courses may affect visa status that allows you to stay in the United States.
Accordingly, students considering withdrawal should consult the Center for International Studies immediately.
Note: All Federal and State policies and procedures pertaining to financial aid eligibility will be enforced. Please contact the Financial Aid Office to
determine the implications of these decisions on financial aid eligibility.
Note: A tuition refund/credit appeal is a separate request submitted to the Business Services Office no later than 45 days after the end of the term or
September 25 th for summer terms.
Note: Request must be submitted no later than one calendar year from the last day of the semester of occurrence.
_______ Initial here indicating you have read the notes above
I. Student Information
Student Name:
Last
Address:
First
SCSU ID:
Street City State Zip
Day Phone: ( ) SCSU Email:
Term / Year of Occurrence (example: Fall, 2010)
II. Check either A or B
A. Request to withdraw from all
courses this term
Submit to: Office of Academic Affairs
Administrative Services 209
St. Cloud State University
720 4th Avenue South
St Cloud MN 56301-4498
Fax: 320-308-5292
Phone: 320-308-3143
B. Request to withdraw from
individual courses this term or
from a course in a previous term
Course(s) under request
Course ID
(Ex:000243)
Dept.
(ENGL)
Number
(191)
Section
(01)
Credits
(4)
Submit to: Dean’s Office of the college/school of major/intended major:
College of Liberal Arts, Kiehle Visual Arts Center 111
School of Arts, Kiehle Visual Arts Center 111
College of Science and Engineering, Wick Science Building 145
School of Education, Education Building A110
Herberger Business School, Centennial Hall 118
School of Public Affairs, Whitney House 101
School of Health and Human Services, Stewart Hall 365
To be completed by instructor:
Last date of
attendance
(required)
Support for request
Signature
__________ _______ ______ ______ ______ ____________ ___Yes ___No ___Neutral _______________________
__________ _______ ______ ______ ______ ____________ ___Yes ___No ___Neutral _______________________
__________ _______ ______ ______ ______ ____________ ___Yes ___No ___Neutral _______________________
III. Extenuating Circumstances (petitions without documented extenuating circumstances will be denied)
____Medical: Documentation of the student’s treatment from a medical or mental health professional, on letterhead, including the
dates of treatment and a telephone number for verification, is required. Medical reasons include serious illness or injury,
mental health treatment, hospitalization, or other care received by the student that prohibits successful completion of the term.
____Call to Active Duty of Armed Forces: Documentation in the form of the call up notice to active duty is required.
____Other: Attach a letter that describes the extenuating circumstances and attach appropriate supporting documentation.
(For example, death or illness of a family member or other significant hardship, etc.)
Student Signature Date ___________
I certify that all information provided is true and correct.
The student will receive written notification of the decision.
****************************************University and College Use Only****************************************
Request result: ____Approved ____Denied
Issued by Office for Academic Affairs July 2012
Signature _______________________________________________
Title ________________________________Date _______________
(Please forward to Office for Academic Affairs)

St. Cloud State University
Late Withdrawal Policy
A late withdrawal is a request to withdraw from a class after the published withdrawal deadline and is
considered only for extenuating circumstances. Typically, requests must be submitted no later than
one calendar year from the last day of the semester of occurrence.
Procedures for Requesting
Consideration of Late Withdrawals
Typically, requests for late withdrawals should be submitted in the semester of occurrence but
no later than one calendar year from the last day of the semester of occurrence. A request for
late withdrawal from an individual course should be submitted to the office of the college or
school offering the course. A request for late withdrawal from all courses should be submitted
to the Office of Academic Affairs. A late withdrawal will be considered only if there are
significant circumstances beyond the student’s control which affected the ability to complete
the course. The circumstances must be documented. Requests without appropriate
documentation or without extenuating circumstances will not be considered. Please refer to the
Late Withdrawal Form for examples. Forms are available at various locations, including college
offices and the Office of Academic Affairs.
If permission for a Late Withdrawal is not granted, the earned grade will appear on the
transcript. If permission is granted, a “W” will appear on the transcript.
All Federal and State policies and procedures regarding financial aid eligibility will be enforced.
Students with financial aid in the form of scholarships, grants or loans may be required to
repay the award if they withdraw or change course load. Students are advised to contact the
Business Services Office (AS 123) and Financial Aid Office (AS 106) before withdrawing from
any class.
Requests for refund/credit will be submitted to the Business Services Office (AS 123) no later
than 45 days after the end of the term or September 25 th for summer terms.
Issued by Office for Academic Affairs
July 2012

MEDICAL VERIFICATION FORM
FOR ACADEMIC APPEALS AND REQUESTS FOR ACADEMIC CHANGE
ST. CLOUD STATE UNIVERSITY
720 Fourth Avenue South
St. Cloud, MN 56301-4498
Student: If you have medical or psychological issues as reasons for an academic appeal or
other academic change, it is necessary to have your medical/psychological provider verify the
extenuating circumstances that are explained in your request. It is not necessary to supply full
medical records. The provider information on this form must be returned with your appeal or
academic change request.
Please sign and date this form which acknowledges that you give permission to your
medical/psychological provider to furnish the required information below.
Student Information:
Student Name: ______________________________________ ID: _____________________
Student Signature: ___________________________________ Date: __________________
Office/Dept./College receiving your request: ________________________________________
If the health care provider prefers to mail or fax the information, complete the following:
Office/Department Name: _______________________________________________________
Building & Room No: __________________________________________________________
Phone (optional): (______) _______________ Fax (optional): (_______) _________________
Mailing Address: (Office/Dept.), (Bldg./Rm. No.),
St. Cloud State University, 720 Fourth Avenue South, St. Cloud, MN 56301-4498
Semester(s) and class(es) impacted by medical/psychological condition being
documented (to be completed by student):
Entire semester (indicate semester and year (Ex. Fall 2012)
Fall______ Spring ______ Summer I ______ Summer II _______
OR List individual classes under request:
Course ID Dept. Number Section Credits Course Name
(Ex: 000243) (ENGL) (191) (01) (4)
____________ ______ _____ _____ ____ _____________________________________
____________ ______ _____ _____ ____ _____________________________________
____________ ______ _____ _____ ____ _____________________________________
____________ ______ _____ _____ ____ _____________________________________
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MEDICAL VERIFICATION FORM (continued)
Provider Instructions:
The student named above is requesting documentation for extenuating circumstances that have
impacted their academic performance. The nature of the request and the permission to release
information are at the top of this form.
Please reply to the questions in the box below. You may supply this on your office letterhead,
print this form on your letterhead or supply the necessary contact information below. If not on
letterhead, please include your office stamp or seal or business card.
Thank you for your assistance.
Provider Name: ______________________________________________________________
Contact information: ___________________________________________________________
Provider Signature: _________________________________________ Date: _____________
Provider: This St. Cloud State University student is asking to withdraw from one or more
classes or appeal an academic issue because of a medical/psychological condition for which
you have treated them.
Please fill out the following portion of this form in its entirety to assist the student in the
withdrawal process.
Medical/psychological condition (brief description): ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Date of onset of condition: ______________________ Duration of condition:_______________
Dates of visits for this condition: __________________________________________________
In your professional opinion would the above condition for which you have treated the student
prevent a student from attending class sessions in a University setting? Yes No
Please identify the dates or duration for which attendance may be impacted: _________________
In your professional opinion would the above condition for which you have treated the student
prevent completion of coursework in a University setting for the above time periods? Yes No
Please identify the dates or duration for which coursework may be impacted: _________________
____________________________________________________________________________
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