Education Course Discharge Form
Please complete this form to document the discharge process from your education course. All information will be used to process your course completion or withdrawal.
Student Full Name
*
First Name
Last Name
Student Email Address
*
example@example.com
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Course Title
*
Instructor Name
*
Type of Discharge
*
Course Completion
Withdrawal
Dismissal
Other
Effective Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Discharge
*
Please rate your overall experience with the course
1
2
3
4
5
Student Feedback or Comments
Instructor/Administration Feedback (if applicable)
Submit Discharge Form
Should be Empty: