Request For College Withdrawal - Georgian College

Request for College Withdrawal

To be used by full-time students wanting to withdraw from all courses in a term

PERSONAL IDENTIFICATION

Student ID number

Date of Birth (mm-dd-yyyy)

Email

Last name (Family name)

(Previous last name)

First name (Given name)

Middle name

Address

Home phone number

City

Province

Postal code

Cell phone number

OSAP Recipient?

Yes

No

International Student?

Yes

No

After the 10th day of the term no refund will be provided and student will be responsible for paying any outstanding

balances on their account. Please submit this form along with your student card to the Office of the Registrar.

Year in Program

Semester

PROGRAM INFORMATION

Term

(i.e. 3)

Year 1

Fall

PROGRAM (MAJOR)

CAMPUS

Year 2

Winter

Year 3

Summer

Year 4

STATE SPECIFIC REASONS FOR WITHDRAWAL

Financial reasons

Personal

Offered employment

Health

To attend another school

To attend another program at Georgian

Difficulties with program

To return home

Wrong program fit/not the rigtht program for me

Other

ADDITIONAL INFORMATION: ___________________________________________________________________________________________

FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT:

In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, R.S.O.

1990, c. F.31, this is to advise you that your personal information is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002. This information

may be used and/or disclosed for administrative, statistical and/or research purposes of the college and/or ministries and agencies of the government of Ontario and the government

of Canada, including, but not limited to, tabulating and reporting data on Key Performance Indicators (graduation rate, graduate employment, graduate satisfaction and employer

satisfaction). You may also be contacted by ministry- or college-authorized third parties for your voluntary participation in surveys to evaluate student and graduate experiences and

outcomes. Information will also be shared with third party service providers who are retained by the college to provide services to students or act as agents of the college (working in

accordance with privacy guidelines). Georgian is required to report student level enrolment-related data to the Ministry of Training, Colleges and Universities under the authority of the

Ontario Colleges of Applied Arts and Technology Act, 2002, S.O. 2002, Chapter 8, Schedule F, Section 6.

I certify that the above information is true and complete. I have read and understand the Freedom of Information and Protection of Privacy Statement.

DOMESTIC REQUIREMENTS

INTERNATIONAL REQUIREMENTS

______________________________________________________

_____________________________________________________

Signature of Student

Date

Signature of Student

Date

______________________________________________________

_____________________________________________________

Signature of Program Co-ordinator

Date

Signature of Counsellor

Date

______________________________________________________

_____________________________________________________

Signature of Counsellor

Date

Signature of International office

Date

For Office Use Only

______________________________________________________

____________________________________________________

Registrar/Designate

Date

Effective Date: ___________________________ Refund Approved

Specify ____________________________________________

Refund $ ______________________________ Financial Aid

_____________________

Accounting_______________________

Yes No

Adjustments ________________________________________________________________________________________________________

Submit to: Office of the Registrar, One Georgian Drive, Barrie, ON L4M 3X9 | T: 705.722.1511 | F: 705.722.5118 | E: registrar@georgiancollege.ca