Withdrawal from Program – River Valley Community College

Student ID #*
Name*
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Telephone
Semester
Year
I am currently enrolled in the following program(s) and would like to withdraw:
Program Degree/Certificate
Withdrawal from a program is not the same as withdrawal from courses or from the College. I understand that as long as I am in good standing with the College I can continue to take courses. I also understand that if I am not a matriculated student, eligibility for financial aid may be affected.
Student Signature*
Date*
MM slash DD slash YYYY

Program	Degree/Certificate