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Office of the Registrar
WITHDRAWAL REQUEST FORM
SUBMIT COMPLETED FORM TO:
CHICAGO/GRAYSLAKE/
800.684.2890 (phone)
312.488.6301 (fax)
[email protected]
ONLINE
800.684.2890 (phone)
312.254.1442 (fax)
SOUTHERN CALIFORNIA
800.684.2890 (phone)
213.615.7286 (fax)
WASHINGTON, D.C.
800.684.2890 (phone)
202.706.5199 (fax)
[email protected]
[email protected]
[email protected]
STUDENT NAME:
__________________________________________________________________
STUDENT ID #: ___________________________________
TCSPP E-MAIL:
Select One
___________________________________________ PHONE #: _________________________ LOCATION: ______________________________________
TERM AND YEAR:
Select One PROGRAM: ______________________________________
___________________________________________ DEGREE LEVEL: ___________________
STUDENT SIGNATURE: _________________________________________________________
DATE:
________________________________________________
E-MAIL (other than school account): _________________________________________________________
OTHER PHONE #:
_______________________________________
ADDRESS:
________________________________________________________________________________________________________________________________
CITY:
_______________________________________________ STATE: ___________________
Current Enrollment:
ZIP CODE: _______________________________________
I plan to complete the courses I am enrolled in before withdrawal OR
(choose one)
I plan to withdraw from the courses I am currently enrolled in
I wish to withdraw. My last semester of enrollment will be:
Reason for withdrawal:
Financial
Health/Medical
Personal/Family
Academic
Other: ___________________________________
Transfer to another school – School if known: __________________________________
Please read and sign below:
“I understand that I am responsible for returning all library books and other borrowed materials and for fulfilling all financial obligations to the institution as
outlined in the Student Handbook. I also understand that withdrawing from the institution means that I will no longer have access to the school’s electronic
resources, including my school email account.”
STUDENT SIGNATURE: _________________________________________________________
Student: Please continue to page 2
DATE:
________________________________________________
FOR OFFICE USE ONLY
AUTHORIZATIONS
I. OFFICE OF THE REGISTRAR
Signature
Date
II. FINANCIAL AID
Signature
Date
III. STUDENT ACCOUNTS
Balance due?
No
Yes
Amount
$
Signature
Date
FOR USE BY THE OFFICE OF THE REGISTRAR
Date of Determination:
Rev. Grad date:
N/A
Courses Removed:
Sys entry date:
Rtn Sem. date:
N/A
YES:
LDA:
Refund %:
NO:
NSLDS WDRWL:
Processed by:
Notifications:
week
Drop Grade:
Unregistered
not registered OR
dropped after 10th day
IT
Facilities
W
ISA
Library
F
APP
Revised: August 2014
Office of the Registrar
Exit Interview Questionnaire:
Describe Your Experience
Must Be Completed by Student
Please answer the questions below. Your feedback will help us improve.
1. What is the most influential factor in your decision to withdraw?
2. What, if any, specific factors led to your decision?
3. Who, if anyone, at The Chicago School had the most positive influence on you?
4. What resources/service(s) were most helpful to you?
5. What resources/service(s) were least helpful to you?
6. What additional resources/service(s) should be provided to Chicago School students?
Rate your Experience
Please check one box for each item.
Explanation of rating scale: 1 is the lowest rating (Strongly Disagree) and 5 is the highest rating (Strongly Agree).
1=Strongly Disagree
2=Disagree
3= Neutral
4=Agree
My “in-class” experience was excellent.
The faculty were accessible and supportive.
The staff were accessible and supportive.
I felt like a part of a community at TCSPP.
1
1
1
1
2
2
2
2
5= Strongly Agree
3
3
3
3
4
4
4
4
5
5
5
5
Rate our Resources
Please check one box for each item.
Explanation of rating scale: 1 is the lowest rating (Poor) and 5 is the highest rating (Excellent).
1=Poor
2=Satisfactory
3= Neutral
4=Good
5= Excellent
Office of the Registrar
1
2
3
4
5
Career Services
1
2
3
4
5
Educational Support Programs (int’l students/study abroad, access accommodations,
1
2
3
4
5
1
2
3
4
5
Student Accounts (including military educational benefits)
1
2
3
4
5
Financial Aid
1
2
3
4
5
Library
1
2
3
4
5
Facilities (Classroom, Lounges, Study Spaces)
1
2
3
4
5
Other (please specify):
1
2
3
4
5
military/veteran affairs)
Student Development (student clubs/organizations, health and wellness, multicultural
programming, new student programs/orientation)
Additional comments:
STUDENT SIGNATURE: _____________________________________________________________________
DATE:
_______________________________________
Thank You!
Revised: August 2014