UNIVERSITY OF MINNESOTA DULUTH

College in the Schools Student Petition

Section A – Personal Information
Student name / Student UMD ID # / email
Current phone
Current street address City State Zip Code
Section B – Request
this petition pertains to
___ Fall ___ Spring Year: / High School
Course Subject & number (e.g. Econ 1003) / Section / Class # (5 digit call number)
 Add course(s) after 10th week  Medical withdrawal
 Cancel course(s) after 10th week Other
State precisely the action requested:
The following facts and documentation support the request:
Counselor signature: Date:
Section C - Recommendations
CITS Director  Recommended
 Not Recommended
Signature
Date / CITS Instructor  Recommended
(If course  Not Recommended
is involved) 
Signature
Date / SIT Director  Recommended
 Not Recommended

Signature
Date

Grades Refund

___ Drop student without a “W” ___ Refund the school district

___ Drop student with a “W” ___ No Refund to the school district Contract #: ______

___ No Refund; billing not sent Comments:

___ No Refund; district on lump sum contract

Office use only

Section D - Action
Dean/Registrar signature Date
 Approved / Comments
 Denied
Effective date / Term/year / By / Date

High School Counselor: Scan and email the completed petition form to

Distribution: Original – Registrar Copy – SIT Director Notify H.S. teacher & Counselor