Student Initiated Withdrawal Form

All fields must be completed accurately in order to process the withdrawal. Students will receive an email upon the receipt of this withdrawal. Students are encouraged to keep this form until the withdrawal is confirmed. Inaccurate or incomplete information will result in a failure to complete the withdrawal and the student will be notified via email of the need to re-submit the form. IVCC has the right to rescind a withdrawal in cases of academic dishonesty or at the instructor's discretion.

* required

*Date
*Birth month and day	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
*Student Last Name
*Student First Name
*Student ID (7-digit number—can be located on your Student ID card or student schedule. This is the purple number on your ID card.)
*Street Address
*City
*State
*Zip
*IVCC student email address:
*Course Prefix, Course Number and Section Number	ACT AGR ALH ANT ART ATO BIO BUL BUS CAD CCE CHM CNC CRJ CSD CSG CSI CSM CSN CSO CSP CSS CSW DFT DLA DRW DSN ECE ECN EDC EGR ELE ELT EMS EMT ENG FEN FIN FLM FRS FSS GDT GEG GEL GEN GER HFA HIS HON HPE HRT HSR HVC IMT ITL JRN LDS LIB LIT MET MGT MKT MTH MUP MUS NUR PHL PHO PHY PRO PSC PSI PSY RBS REA RED SDT SFC SOC SPH SPN SSK SWK TAM THE THM WED WHS WLD WND
*Instructor Name
Reason for withdrawal. Select the primary reason.	COVID-19 Work conflicts Loss of child care Car/transportation problems Military deployment Illness/medical Coursework too difficult Time management issues Online format not working Overextended Family issues Excessive absences Not passing course Never attended Changed major
	By clicking the submit button, I am agreeing that I have read the instructions and guidelines regarding student withdrawals. I understand that by completing the form below, I am authorizing IVCC to remove me from the course. I understand that a withdrawal may impact my financial aid and/or insurance status. I also understand that entering my student ID number serves as my electronic signature.