Petition to repeat Dental Hygiene course/return to program – form

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General Information

Name(Required)

First Last A Number

Email(Required)

Enter Email Confirm Email

Phone

Return to Term

Fall

Spring

Year

Course information

Repeat Course(s)(Required)

Click the + to the right to add more than 1 course.

Extenuating Circumstances and Documentation

Complete the form with all required items. Students will not be provided an opportunity to meet in person with the committee. Therefore, it is important the appeal include all necessary information. Unexplained or excessive delay between discovering the necessity of filing this petition and submitting it may be grounds for denial. Returning in a future semester is dependent on space availability.
PLEASE CHECK THE REASON(S) YOU ARE RETAKING THE COURSE (DOCUMENTATION MUST BE INCLUDED/ATTACHED AT BOTTOM OF FORM)

Extenuating Circumstances and Documentation

Extenuating circumstances are verified cases of accident, illness, or other life changing events beyond the control of the student (describe below).

The previous grade was the result of not meeting requirements for passing grade or technical skill level.

Course repetition is required in order to meet program completion.

Other. (Describe below)

Extenuating circumstances description(Required)

Extenuating circumstances beyond a student's control could include but are not limited to the list below. Experiencing and documenting an extenuating circumstance is not automatic cause for petition approval.

Documented death of an immediate family member (spouse, mother, father, guardian, sister, brother, son, or daughter)
Documented major medical issue experienced by the student or immediate family member (designated above)
Documented domestic violence
Documented involuntary call to active military duty
Documented other extreme circumstances (case by case basis)

The following circumstances are not considered extenuating and beyond the student's control:

Not knowing the deadline or procedure
Work conflicts
Voluntary overtime
Not needing or wanting a class, not doing well in a class, not knowing you were enrolled in a class
Having too heavy of a course load
Wishing to improve your GPA

Other (please describe)(Required)

Non-passed Course(s)

As a result of not passing the course(s) identified above, please provide information to the following criteria:

Identify areas that contributed to lack of success.

B. Identify how you will improve in the course(s) and program to ensure success, if reinstated.

Extenuating Circumstances Documentation.(Required)

Please upload scanned documents as either PDF, DOC, DOCX, JPEG, GIF or .PNG.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 20 MB.

Signature

By providing this information, I understand that it will be used as part of an education improvement plan, which includes auditing some courses for current subject matter. I also understand that I will be required to repeat all failed courses and pass with a 75% or better to move forward in the program.

General Information

Course information

Extenuating Circumstances and Documentation

Non-passed Course(s)

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