Former Student Application for Readmission - Patrick Henry College

Former Student Application for Readmission
Degree Seeking
PERSONAL INFORMATION
Legal Name: __________________________________________ Maiden Name: _________________
Last First Middle
PHC ID: _____________ Social Security Number: * _________________________ Birth Date: _________
Have you ever enrolled under another name? No Yes, _________________________________________
Contact E-mail: ______________________________________________________________________________
Permanent Phone: ( ) ________ - ___________ Contact Phone: ( ) ________ - _____________
Permanent Address:
Local Address (if different)
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
City State Zip
City State Zip
* The SSN is required for federal reporting purposes on Form 1098-T.
Due to Commonwealth of Virginia law, information on students who apply to Virginia colleges may be submitted to the Virginia State
Police.
DEADLINES
The Application for Readmission follows the same schedule of deadlines as the traditional degree seeking application for admission.
See the admissions webpage for details.
ENROLLMENT INFORMATION
Anticipated Term: Fall Spring Summer 20___ Campus: PHC Web
Last Enrolled: Fall Spring Summer 20___ Campus: PHC Web
Anticipated Status: Full-time Part-time Anticipated Housing: On-Campus Off-Campus
Major while enrolled: ________________ Intended Major (if different): ___________________
ACADEMIC INFORMATION (since prior enrollment)
Institution Name, Location Dates Attended Credits Completed
_____________________________________________________________________________________
_____________________________________________________________________________________
Please forward all transcripts since prior enrollment to the Office of the Registrar
EMPLOYMENT INFORMATION (since prior enrollment)
Employer Name Dates Employed Position
____________________________________________________________________________________
____________________________________________________________________________________

BACKGROUND INFORMATION
1. Have you ever been placed on disciplinary suspension (academic or student life)?
Yes
No
If you were placed on academic suspension, then you must demonstrate improved academic ability evidenced by the
completion of 12 semester credits with a 2.5 cumulative GPA at an accredited college or university. Additionally, then
you must submit a written request to the Dean of Academic Affairs stating the reasons you wish to re-enroll and
detailing academic and other pertinent activities engaged in during the absence. If these requirements are satisfied,
then you may be re-admitted on academic probation.
If you were placed on student life disciplinary suspension or expulsion, you must submit a written request to the Dean
of Student Affairs stating the reasons you wish to re-enroll and detailing the steps you have taken to address the
issue(s) that led to your suspension or expulsion. The Dean may also require a personal interview with you before a
re-admission decision is made. If the Dean believes you should be re-admitted, then you may be re-admitted on
disciplinary probation.
2. Have you ever been convicted of a misdemeanor or felony (excluding any minor traffic violations)
Yes
No
If yes, please explain:
3. Why did you withdraw from PHC?
CERTIFICATION
I understand that this form must be received by the Office of Admissions by the appropriate deadline in order to reviewed in a
timely manner. I also understand that the Director of Admissions may request additional application materials before a re-admission
decision is made.
By signing, I certify that the information provided is accurate. Incorrect or omitted information may jeopardize my continuing
enrollment. I understand that attendance is a privilege granted to those who have accepted Jesus Christ as personal Savior, who can
succeed in this academically rigorous environment, and who can live in a manner consistent with the community's standards outlined
in the Student Handbook.
I understand that Patrick Henry College is a distinctively Christian educational institution that seeks to maintain a Christ-centered
focus in all it does. I certify that I have read and fully and enthusiastically subscribe to the College’s Statement of Faith, and I desire
to be part of the Christian community at Patrick Henry College. I have reviewed the Student Handbook (available online at
www.phc.edu), and willingly affirm the Student Covenant and Student Honor code.
If I am offered admission and accept the offer, I will abide by all the policies and procedures of the College, and I voluntarily agree
to abide by the Patrick Henry College Standards.
Student Signature: ________________________________________________
Parent Signature: ________________________________________________
Date: _____________
Date: _____________
(if student is under 18)
Patrick Henry College - 10 Patrick Henry Circle - Purcellville, VA 20132
Office of Admissions - P: (888) 338-1776 - F: (540) 441-8119