This petition is to be used to request to repeat one of Dave Smith's courses only.  This information will go to Mr. Smith only, and will not be shared with any other instructor.

As on all forms, be sure you have your data backed up in another document, and in your lab notebook.

Submitting Assignment: Administrative Withdrawal

The course, section number and term for which you wish to be reinstated (e.g., Mth 151-40 summer 2010, Mth 173-01 fall 2011, Phy 121-51 spring 2012, etc. ):

If you have an access code, enter it in the box below.  If you don't have one, it's not 100% necessary.

Access Code:
Confirm Access Code:

Your Name:

Your VCCS email address. 

List your previous enrollments in this course, giving course number, section, semester and year taken, name of instructor and your grade for that course (e.g., Mth 152-40, Spring 2010, Dave Smith, course grade D).  You should check your VHCC records to be sure you information is correct  (www.vhcc.edu   > My VHCC; log in etc.).

Provide your detailed reasons for this petition.  You may in addition email the instructor with documentation to support your request.

You should email the instructor with your EMPLID#, and a note indicating that you have submitted this form.  If the instructor does not respond within 48 hours, email him once more.