Dual Enrollment Program Termination Request Form
Use this form to request termination or withdrawal from a dual enrollment program or specific dual enrollment courses. Please provide accurate student, school, and enrollment details so the request can be processed.
Student & Program Information
Student Full Name
*
First Name
Middle Name
Last Name
Preferred Name (if applicable)
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
High School Name
*
College or University Name
*
Dual Enrollment Program Name
*
Student or Program ID
*
Current Grade Level
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Other
Academic Term or Semester Affected
*
Please Select
Fall
Spring
Summer
Winter
Full Year
Other
Termination Request Details
Requested Termination Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Schedule conflict
Transfer to another school
Academic difficulty
Family/personal reasons
No longer wish to participate
Program requirements not met
Other
Explanation or Additional Context
Last Day Attended / Last Date of Participation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scope of Withdrawal
*
One course
Selected courses
Entire dual enrollment program
Enrollment & Academic Impact
Current Courses Enrolled In
*
Discussed Termination with School Counselor/Advisor?
*
Yes
No
Will Withdrawal Affect Credits, Transcript, or Graduation Plan?
*
Yes
No
Not Sure
Known Withdrawal Deadlines or Holds
Additional Academic Impact Notes
Contact & Processing Follow-up
Parent/Guardian or Authorized Contact Name
First Name
Middle Name
Last Name
Role or Relationship to Student
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone
Text Message
Other
Supporting Documents
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