You must have JavaScript enabled to use this form. Personal Information Student First Name Student Last Name I am a GRCC student a healthcare professional filling out the form on the students behalf assisting a student on their behalf Provider information Please provide your information. Name Company Email Phone GRCC Email? Please note that we will send all communications to your GRCC student email. I forgot my GRCC email. Your username is the same as your MyGRCC Login. Your login will be username@email.grcc.edu. You must enter the @email.grcc.edu after your username. Student Phone Number Student email Student ID Semester Information Semester Winter Summer Fall Is it past the 70% mark of the semester you’re requesting? Yes No STOP HERE! Your request will NOT be processed. You must withdraw yourself in your Online Center. Class Information Please list the class or classes you would like to withdrawal from. Course Prefix & Number: Credit Hours: Approximate Last Date Attended: Operations Course Prefix & Number: Credit Hours: Approximate Last Date Attended: Aid Information Have you previously requested a Late Semester Hardship Withdrawal? Yes No What semester? Did you receive Financial Aid (grants, loans, scholarships) or Veterans/Military Benefits? Yes No A withdrawal may result in a need for you to repay money that was dispersed. It is your responsibility to investigate with appropriate campus offices. Financial Aid - (616) 234-4030 Veteran's Benefits - (616) 234-4129 Cashier Office - (616) 234-4020 Narrative and Documentation Narrative and documentation information that may be helpful to provide: Dates of the cited hardship. Explanation of how the hardship impeded the ability to be successful in the class (or unable to attend). Supporting documentation such as letter(s) from a healthcare provider. Occasionally students may wish to withdraw from one class during a semester while remaining enrolled in other classes. In these circumstances it is helpful to provide a brief explanation why this is the case. Provide a brief narrative of why you need to withdrawal from you class/classes. Upload your documentation One file only.100 MB limit.Allowed types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip. Signature I understand this process is only for withdrawals past the 70% mark in the semester and there is NO refund with this process. I understand there may be a Financial Aid or Veterans/Military Benefits impact. It is my responsibility to investigate and repay any funds owed. I have provided a narrative and available documentation. By submitting this form I confirm that all the information submitted here is accurate.