Dean's Advising Form
College of _____________________________________________________________________
Advisement for Academic Relief
Name: _______________________________________________________________________
Date: _______________________________________________________________________
ID#: _________________________________________________________________________
Address: ______________________________________________________________________
_____________________________________________________________________
Telephone: ___________________________________________________________________
E-mail: ______________________________________________________________________
Specify semester for requested academic relief: _______________________________________
I am requesting the following academic relief through the Academic Relief Committee.
Withdrawal _____
Incomplete _____
Specific Course Drops _____
Other ___________________________
List Course name, number, and Semester (e.g. Math 1526 Fall XXXX):
Course Drops __________ Incompletes __________ Semester _______________
__________ __________ _______________
__________ __________ _______________
__________ __________ _______________
I understand that the Academic Relief Committee will keep all personal/medical information confidential and that information will not be shared or discussed with academic officials.
Student ________________________________________________ Date__________________
Signature
I have reviewed the student’s request and have the following comments regarding his/her requested academic relief and its effect on the student’s academic future:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Academic Dean/Advisor ___________________________________Date___________________
Signature
If you are an Undergraduate International student you need to obtain a signature from the Cranwell International Center. If you are a Graduate International student you need to obtain a signature from an international advisor at the Graduate School.
ญญญญญญญญญ_______________________________________________________Date__________________
Signature
Return form to the Cook Counseling Center
240 McComas Hall to begin application for Academic Relief
Cc: Dean
revised 11/17/06