Intent to Withdraw from Academy
Please complete this form to formally request withdrawal from the academy. Your responses will help us process your request and improve our services.
Student Full Name
*
First Name
Last Name
Student ID Number
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Program or Course Name
*
Current Year/Level
*
Please Select
Freshman
Sophomore
Junior
Senior
Graduate
Other
Reason for Withdrawal
*
Personal reasons
Financial reasons
Academic challenges
Transfer to another institution
Health concerns
Other (please specify)
Last Date of Attendance (or intended withdrawal date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Would you like to provide feedback or suggestions to help us improve?
If you are under 18, please provide parent/guardian name and contact information
Signature of Student (or Parent/Guardian, if under 18)
*
Submit Withdrawal Request
Submit Withdrawal Request
Should be Empty: