Version ASP – 1QAppeal form.3.8.12.ac

Clark College Academic Standards Policy Appeal Form for One (1) Quarter Dismissal

To appeal the One (1) Quarter Academic Dismissal, you must do the following:

Complete this form (must be typed) and hand deliver a printed copy to Cindi Olson in the Office of the Vice President of Student Affairs, Gaiser Hall 215, before the deadline stated in the email sent to you. Remember to fill out the form completely. This is your best chance to give the Academic Standards

Committee the information they need to make a good decision.

Student ID Number:

Current Telephone Number:

Last Name:

First Name:

Middle Initial:

Address: City: Zip:

Student E-mail Address: @students.clark.edu

What quarter and year are you requesting to return? Quarter Year Please answer all of the six questions below as completely and specifically as you can. Type responses on this form and print a copy. Please use a separate sheet if needed and print ALL pages necessary to be included in this appeal.

1. What program are you completing at Clark College?

AA AST AAS AAT Certificate Not pursuing a degree or certificate at Clark

What is the title of your program? 2. In the Academic Intervention status, you were required to attend a group workshop or a specific HDEV class.

What is the date of the workshop you attended? _.

Please bring a copy of your Academic Success Plan that was completed in the workshop. 3. What are the specific reasons you are appealing this sanction to be academically dismissed for one (1) quarter?

Please use a separate sheet if needed and print ALL pages necessary to be included in this appeal.

Version ASP – 1QAppeal form.3.8.12.ac

Version ASP – 1QAppeal form.3.8.12.ac

4. Do you have official documentation (medical, work related, etc.) to support your explanation of why you are appealing this sanction? If so, please describe it briefly here and include documents with this form.

5. What specific activities or behaviors will you do to improve your grades? Please use a separate sheet if needed and print ALL the pages necessary you would like to be included in this appeal.

Version ASP – 1QAppeal form.3.8.12.ac

6. List what classes you would hope to attend this quarter and state how many credits that includes. Please prioritize the classes in case the committee only allows one or two classes. You may want to consider repeating a failed class to improve your GPA.

Class / Course / Credits Check if Repeating Course Example: HDEV 116 / Motivation &Study Skills/ 2 credits 1st choice

2nd choice

3rd choice

4th choice

5th choice

Version ASP – 1QAppeal form.3.8.12.ac

By signing and submitting this appeal to return to college, I certify that:

I understand that any classes recommended to me by the Academic Standards Committee are on a space available basis and are not guaranteed.

I understand that the Academic Standards Committee may restrict my enrollment by specifying the number of credits or courses that I may take.

I understand that if my appeal is successful, I will be on Academic Intervention status until I return to good academic standing.

I understand that the decision of the Academic Standards Committee is final.

I have read the Academic Standards policy found at:

http://www.clark.edu/about_clark/academic_standards/

Note: Before signing, please make sure you copy and submit all supporting documents with this appeal. Student Signature Date _

Print Name

Clark College does not discriminate on the basis of race, color, national origin, sex, disability, age, religion, sexual orientation, gender identity, gender expression, political affiliation, creed, disabled veteran status, marital status, honorably discharged veteran or Vietnam-era veteran status in its programs and activities. Alternate format of this document is available upon request. Please contact Disability Support Services at (360) 992-2314 or (360) 991-0901.