Withdrawal From College Form
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1HIBBING COMMUNITY COLLEGE
Withdrawal from College Form
Term: Fall 20_____ Spring 20_____ Summer 20_____
Name__________________________________________________ X_______________________________________
Last
First
MI
Student’s Signature
________________________
___________________________
_________________________________
Student ID #
Date of Birth
Today’s Date
Current Address:______________________________________________________
_________________________
Street/ P.O. Box
City
State
Zip
Telephone No.
Permanent Address: ___________________________________________________
_________________________
Street/P.O. Box
City
State
Zip
Telephone No.
Veteran: YES NO
REASON FOR WITHDRAWAL –
Check all that apply:
1.
Decided to attend a different college.
12.
Wanted to live nearer to my parents or loved
2.
Wanted to move to (or was transferred to)
ones.
a new location
13.
Financial, explain:
3.
Dissatisfied with my grades.
______________________________________
4.
Inadequate study habits, lack of motivation.
______________________________________
5.
Wanted a break from college studies.
14.
Illness.
6.
Impersonal attitude of college faculty or staff.
15.
Uncertain about career/major.
7.
Desired major was not offered by this college.
16.
Personal, family.
9.
Disappointed by quality of instruction.
17.
Cultural/Racial differences.
10.
Accepted a full-time job or job conflict.
18.
Other (Please
11.
Academic Advising was inadequate.
specify)_______________________________
I plan to return to HCC to complete a degree.
Yes
No
Current housing: On-campus _______ Off-campus _____
HCC HOUSING
I understand that it is my responsibility to cancel my housing contract.
I understand I must rescind (cancel) my housing contract with the Associate Dean of Student Services.
I further understand that I am responsible for the charges specified in my housing contract.
Date ________________________________
Student Initials_______
FINANCIAL AID
If you totally withdraw or stop attending classes, federal regulations require us to calculate a repayment of your federal
financial aid based on your last date of attendance. Therefore, if you have been awarded financial aid, any tuition and/or
housing refund may be applied to repay your financial aid. Failure to successfully complete two-thirds (67%) of the
cumulative credit hours attempted may make you ineligible for federal student financial aid at HCC in the future.
Date ________________________________
Student Initials________
Counselor/Advisor Signature ___________________________________________ Date ______________________
This document may be available in alternative formats to individuals with disabilities by calling 218-262-7200 or 1-800-224-4422.
The Minnesota State Colleges and Universities system is an Equal Opportunity employer and educator.
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