Academic Suspension Intent to Re-Enter - Formstack

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Academic Suspension Appeal

NOTICE: For the Financial Aid Progress Appeal, visit Student Forms & Policies and click on FINANCIAL AID FORMS.

Committee Review

Yes No

Approve/Deny Request

Approve Deny

Hold Removed

Yes No

Advisor Notified

Yes No

Student Notified

Yes No

Referral Made

Yes No

Referral

Student Name*

First Name

Last Name

FVTC Student ID Number*

Ex: 123456789

Email Address*

Phone Number*

Ex: 920-555-5555

I am:*

Appealing my suspension due to extenuating circumstances

Suspension Appeal

Which of the following situations applies to your appeal of the suspension?*

Change in work status Medical condition Family circumstances

Other:

Change in work status - which best describes your situation?*

Required overtime or other required schedule change Reduced hours resulting in increased childcare need, layoff or job loss

For "Required overtime or required change in schedule" you need to provide:

A letter from the employer that includes effective dates and whether the increase in hours or schedule change was mandatory

Please complete the acknowledgement below and upload the appropriate documentation.

For "Reduced hours resulting in increased childcare need, layoff, or job loss", you need to provide one of the following:

A letter from the employer stating the dates of the change
A separation letter
Unemployment documentation

Please complete the acknowledgement below and upload the appropriate documentation.

Medical condition - which best describes your situation?*

Serious illness or change in health status Surgery/Hospitalization Mental health issue Dental emergency

For "Serious illness or change in health status", you need to provide one of the following:

Letter stating doctor advised period of home rest and permission to return to school
Records of doctors visits and permission to return to school

Please complete the acknowledgement below and upload the appropriate documentation.

For "Surgery/Hospitalization", you need to provide one of the following:

Letter from doctor stating advised period of recovery
Record of doctor visits
Hospitalization records
Copies of medical bills documenting illness/injury

Please complete the acknowledgement below and upload the appropriate documentation.

For "Mental health issue", you need to provide:

Letter from doctor, therapist, or counselor stating student is well enough to return to school

Please complete the acknowledgement below and upload the appropriate documentation.

For "Dental emergency", you need to provide one of the following:

Record of dental visits
Letter from dentist
Letter stating dentist advised a period of rest

Please complete the acknowledgement below and upload the appropriate documentation.

Family situation - which best describes your situation?*

Child's medical condition Daycare issue

For "Child's medical condition", you need to provide one of the following:

Records from daycare/school that child was required to be kept home and alternative care was not
available
Records from doctors visits
Letter stating doctor advised period of rest
Hospitalization records

Please complete the acknowledgement below and upload the appropriate documentation.

For "Daycare issue", you need to provide one of the following:

Letter from former daycare provider
Letter from new daycare provider

Please complete the acknowledgement below and upload the appropriate documentation.

Other - which best describes your situation?*

Death of a loved one Eviction Assault/Domestic abuse

Other:

For "Death of a loved one", you need to provide one of the following and include your relationship to the deceased:

Obituary
Funeral program
Death certificate
Letter from counselor

Please complete the acknowledgement below and upload the appropriate documentation.

For "Eviction", you need to provide one of the following:

Eviction notice
Letter from transitional housing program

Please complete the acknowledgement below and upload the appropriate documentation.

For "Assault/Domestic Abuse", you need provide one of the following:

Police report
Court documentation
Letter from clergy, social worker, counselor, or doctor

Please complete the acknowledgement below and upload the appropriate documentation.

Upload required documentation here:*

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I understand what is required and have uploaded the appropriate documentation.*

Yes No

You have answered that you understand what must be provided for special circumstance appeal of your suspension. Please enter any additional information you feel is relevant to your situation. You will receive an email confirmation of your submission for your records - please verify that you have access to the email you provided above.*

In 4-6 sentences, please provide a brief explanation of circumstances that prevented you from meeting academic standards and how you have addressed these circumstances to provide a more successful academic endeavor in the future.*

When reviewing your circumstances please provide three strategies that if followed, will help to produce more successful academic outcomes. In 4-6 sentences, please use the space below to describe what you will do differently if reinstated to the college.

Strategy 1*

Strategy 2*

Strategy 3*

Identify and list a minimum of three campus resources you will use to assist you in identifying solutions and overcoming barriers if reinstated to the College. For campus resources and support services, please visit: www.fvtc.edu/MyFVTC.

Campus Resource 1*

Campus Resource 2*

Campus Resource 3*

How will the changes you described and the resources chosen increase the likelihood of success should you be reinstated to the college?*