Students with extenuating, documented circumstances may be eligible for an administrative withdrawal. This form can be used for administrative withdrawal requests after the semester has ended. If you are currently enrolled in the course for which you are seeking an administrative withdrawal, please check the course’s withdrawal deadline, and if it has passed, please use the Administrative Withdrawal for Current Semester Course form. 

Extenuating circumstances should meet one of the following criteria:

  1. Those that interfere with a student’s ability to attend class- resulting in an inordinate number of absences, or
  2. Prevent a student from withdrawing from the class before the withdrawal deadline

Extenuating circumstances should be supported with appropriate documentation, and should follow these guidelines:

  • Documentation should be signed, dated, and on organization (employer, doctor, court, etc) letterhead
  • Can include (but are not limited to):
    • Court documents
    • Medical documents
    • Signed and dated letter from employer
    • Signed and dated letter from doctor
    • Document issued by a third-party, such as school, hospital, company, etc

Documents that are handwritten and from friend, coworker, neighbor, etc are not accepted as support for an administrative withdrawal. Documents provided must align with the dates and extenuating circumstances stated in this form. By completing and submitting the form below, you are stating that you wish to be considered for an administrative withdrawal, per LCCC’s Administrative Withdrawal Policy.

  • Your request will be reviewed and considered based on extenuating circumstances described in your request
  • Documentation to support the extenuating circumstances is requested
  • If you need more space than this form provides, please complete your explanation in a Word document and attach using the additional documentation box provided below

Watch your LCCC email account for results of your appeal and requests for additional information as needed.


Please complete and submit the form below:


  • Name * Required
  • Courses from which you wish to be administratively withdrawn. * Required
    Use the plus sign at the right to add additional lines. You may list up to six courses.
  • If your withdrawal is related to COVID-19, please select a reason from the list below:
  • Please provide documentation

    Please upload documentation using the upload boxes below to support this request.
  • Accepted file types: doc, docx, pdf, jpg, png.