Late Course Withdrawal Petition

Instructions

Complete this form fully (including Personal Statement)

Student Information

First Name*

Last Name*

Student ID*

Class Year*

UMass Email*

Phone Number

Majors*

Course Information

for the course in which you are seeking a withdrawal.

Department*

Course #*

3 digit number- may include additional letters/numbers

Class #*

5 digit number

Title*

# of Credits*

Semester

Instructor Name*

Reason for Request*

Never Attended Personal Illness Personal and/or family concerns Work Circumstances No Record Drop

Other:

check all that apply

Documentation Needed:

all documentation needs to be submitted to advising@hfa.umass.edu

Medical Verification from University Health Services or personal physician detailing severity and dates of illness
Description of problems: verification by e.g. counselor, CCPH, Dean of Students Office, Clergy or other appropriate parties
Employment verification (including hours per week for the same period in question)
Statement of problem verification from appropriate sources

If Attendance and Performance Verification is needed from your instructor, an Academic Dean will send it to them to be completed.

Personal Statement*

Please use this space to describe your circumstances. At the end of your statement include a list of documentation you anticipate being submitted by you or on your behalf. We cannot make a decision regarding your petition without documentation.