COVID-Related Withdrawal Supplementary Form

This form is for students who are withdrawing from all or any of their courses during a single academic term due to the impact of COVID-19.

Student Information

Student ID

First Name

Last Name

MUIH Email

Phone Number

Advisor Name

Trimester Withdrawing From

Do you intend to return?

Covid Reason

Other Reason Details

Are you interested in learning more about student support services you may continue to qualify for now or as you resume courses? These include career counseling, academic coaching, mental health counseling, and disability services.

Please state your specific reason for the request and any details you wish to be considered. If you are requesting a partial withdrawal, please include why only the specific course(s) is/was impacted. Decisions will be rendered based solely on the information you provide in this form and the associated documentation.

Please attach all relevant information or recent supporting documentation for this request. Requests without verifiable third-party supporting documentation will be denied.

Course Information

Courses withdrawing

Course Number (ex. NUTR 600)

Section (ex. 200)

Credit Hours

Courses remaining enrolled

Course Number (ex. NUTR 600)

Section (ex. 200)

Credit Hours

Additional Information

Submission of this request does not guarantee approval. Students must withdraw from their course(s) prior to submitting this request. If the withdrawal(s) is/are approved due to COVID-19, the "W" will be converted to an "E" (Excused Withdrawal) grade.
University records will indicate that your approved withdrawal is related to COVID. This means that you withdrew from courses due to specific events beyond your control affecting your ability to complete the course(s).
Students who withdraw from all of their courses are NOT required to withdraw from the university; however, those who do wish to withdraw from the university must complete the Program or University Withdrawal Form.
Students who wish to withdraw from all of their courses in a term but remain an active student at the University are not required to complete an additional forms; however, students who wish to remain active without enrolling in classes for the following academic term must complete a Voluntary Break in Enrollment Request Form.
COVID-related withdrawals do not count negatively towards your academic or progress standing.
Will you receive a refund? Under normal circumstances, per Title 5, section 58508, refunds are not allowed after the first two weeks of instruction, or ten percent point of the length of the course. However, regulatory authority has been granted to MUIH, to waive this provision and grant a refund of enrollment fees for any students on financial aid who withdraw from all their courses in an academic term after March 13, 2020 due to the coronavirus outbreak. If you are eligible for a refund, please allow 4-6 weeks for processing. Students are encouraged to reach out to Student Accounts with any questions.
Is there a deadline to make this request? Yes. You must submit this COVID-specific withdrawal form within 2 business days of withdrawing from your course(s). Completion of this form is required to process the withdrawal of courses related to COVID-19.
Students must complete this request and submit recent verifiable, third-party documentation within the term for which the student is requesting COVID-related excused withdrawals.

STUDENT CERTIFICATION OF EXCUSED WITHDRAWAL DUE TO COVID-19

By signing below, I certify under penalty of perjury that all information I provided on this petition is legitimate and accurate. My Withdrawal was necessary because it was difficult or impossible for me to attend one or more trimesters beyond March 13, 2020, because I was actively engaged in responding to, or impacted by, the novel Coronavirus, COVID-19.

Student Signature

Date