Withdrawal Form - Finger Lakes Community College

OR
OFFICIAL WITHDRAWAL FROM ALL COURSES
Complete this form; then submit to Educational Planning & Career Services via fax, mail, or in person.
Name: ____________________________________________________ FLCC ID # ______________________ Telephone: _____________________
Address: ________________________________________________________________________________________________________________
Term withdrawing from (check one only; use separate form if withdrawing from more than one semester):
____ Fall
____ Winter Session. If withdrawing from winter session, but plan to attend Spring session, please sign and date: ______________________________________
____ Spring Signature Date
____ Summer
1. The effective date of this withdrawal is the date this completed form is received in Educational Planning and Career Services.
2. Reason for my withdrawal: ( a) attending another college (please specify __________________________) (b) lack of financial aid
(c) relocating (d) employed/seeking employment (e) academic problems
(f) unable to find housing (g) transportation (h) medical
(i) other (please explain) _______________________________________________________________________________________________
3. If I borrowed a loan to attend FLCC, I will visit or call the Financial Aid Office (585 785-1276) before submitting this form.
4. Select and complete one of the following:
I AM WITHDRAWING BEFORE THE START OF THE SEMESTER (see attachment for semester start date):
I understand that I will be dropped from all my classes, I will not owe any tuition for the semester checked above, and any financial aid awards I expected
will not be awarded this term.
Initial here: ____________
I A I AM WITHDRAWING AFTER THE START OF THE SEMESTER (see attachment for semester start date; initial all of the following):
If my financial aid has not yet been finalized, I will contact the Financial Aid Office immediately to determine the status of my financial aid application. I
understand I will be responsible for full payment of my bill for tuition/fees. Find more information at www.flcc.edu/studentaccounts (Refund Policy for
Credit & Credit Free Courses).
Initial here: ____________
If my financial aid has been finalized, but 60% of the semester has not passed at the time of this withdrawal, I understand that I will not receive my full
financial aid award and it is very likely I will owe money to the College for which I am responsible. Find more information at
www.flcc.edu/studentaccounts (Return of Title IV Financial Aid Funds Policy).
Initial here: ____________
Eligibility for financial aid in future semesters may be affected by this withdrawal.
Initial here: ____________
I understand that my academic standing (progress toward my degree) can be negatively affected by my withdrawal and depending upon the date of this
withdrawal, “W” grades will be assigned. Find more information at www.flcc.edu/academics (Academic Requirements and Policies, Academic Standards).
Initial here: ____________
________________________________________________________ ____________________________
Signature Date
Office Use Only
Receiving Office ___________________________________________________ Date completed form was received _____________________
Educational Planning & Career Services log Processed by _____________________ Date: _______________________
Student Records: Dropped from classes SHIS Processed by: ____________________ Date: ______________________
Student Accounts: Refund (if applicable) Fin. Aid. Title IV Recalc Bill - Balance Owed (if applicable)
FINGER LAKES COMMUNITY COLLEGE
Educational Planning & Career Services
3325 Marvin Sands Drive, Canandaigua, NY 14424
‘One Stop’ Phone: (585) 785-1267 Fax: (585) 394-8304
Processed by: ____________________ Date: ______________________
Page 1 of 3

SEMESTER START DATES
Fall 2013: September 3, 2013
WinterSession: December 26, 2013
Spring 2014: January 23, 2014
Summer 2014: varies
Page 2 of 3

1. Name
2. SS# - - or ID#
3. From what term are you withdrawing?
STUDENT WITHDRAWAL SURVEY
To complete your withdrawal, return this survey
with your Student Withdrawal Form.
3a. Term: SP Spring SU Summer 3b. Year:
FA Fall JP Jan Plan for example: 12
4. At which campus did you take most C Canandaigua - Main Campus
of your courses? G Geneva Campus Center
V Victor Campus Center
W Wayne County Campus Center - Newark
B Withdrew before attending class
I Internet/On-line Course(s)
5. Do you think you will return to FLCC? 5a. Y Yes N No
If “Yes,” when do you think you might return?
5b. Term: SP Spring SU Summer 5c. Year:
FA Fall JP Jan Plan for example: 12
6. Are you currently attending, or do you plan to attend
another college (not FLCC) in the next year? 6a. Y Yes N No
6b. If “Yes,” which college?
REASONS FOR WITHDRAWAL
Please identify the primary reason(s) why you stopped attending FLCC. Check all of the
reasons (7 through 18) that apply to you.
THE PROGRAM I CHOSE WAS NOT WHAT I EXPECTED. (Choose from the
explanations below the ones that apply to you.):
7. Another FLCC program might be better, but I need advice.
8. FLCC does not offer a degree or certificate program relevant to my needs, but I
would be interested in the following program—Identify:
8a.
9. The program was less challenging than I expected, and I did not feel that I was
learning enough.
10. The program was more challenging than I expected, and I would need additional
preparation or extra tutoring help to succeed in the program.
11. The time commitment was greater than I expected. I cannot devote sufficient time to
succeed in the program right now.
12. My educational objectives changed in the following way(s)—Explain:
12a.
FINANCIAL REASONS. Choose all that apply to you:
13. I received financial aid, but the expenses of attending FLCC were still more than I
could afford.
14. I did not apply for financial aid, and the expenses of attending FLCC were more than
I could afford.
15. Other—Explain:
15a.
16. I’M RELOCATING.
17. I’M EMPLOYED OR SEEKING EMPLOYMENT.
EXPERIENCED ACADEMIC PROBLEMS. Choose all that apply:
18. I did not feel that the program was suitable for transfer to another college
19. I decided not to continue because of poor grades
20. I have had a poor experience with or bad treatment by an
FLCC faculty or staff member.
REGISTRATION PROCESS was difficult or problematic. Choose all that apply:
21. Too many courses are full and closed before I can register.
22. Limited availability of courses at times I can take them—Explain:
22a.
23. Limited availability of on-line courses
HOUSING ISSUES. [Choose all that apply.]:
24. Unable to find satisfactory housing
25. Had roommate problems
26. Housing was unsuitable (e.g., landlord problems, repair issues, etc.)
27. Evicted from housing
28. TRANSPORTATION ISSUES
29. HEALTH-RELATED PROBLEMS
30. SOCIAL/PERSONAL PREFERENCES (e.g., nothing to do after class or on
weekends, didn’t adjust to the campus community, didn’t make friends, didn’t connect
with faculty/staff, want to live closer to home, etc.)
31. OTHER REASON(S)—Explain:
31a.
Thank you very much for completing this survey!