Return your completed form to:
Secured Fax: 719-255-3911
Mail:
Campus Wide Extended Studies
1420 Austin Bluffs Parkway
Colorado Springs, CO 80918
In-Person: Campus Wide Extended Studies (across the street from UCCS campus)
1861 Austin Bluffs Parkway, Ste. 100 (University Office Park)
Add/ Drop/ Withdrawal Request Form
Year
Semester:
Spring
Last Name
Summer
Fall
Questions: cwes@uccs.edu, 719-255-3498, www.uccs.edu/extendedstudies
Student ID #
First Name
Email Address
Middle Name
Daytime Phone
Former Name, if applicable
Date of Birth
I wish to ADD the following course(s):
TITLE OF COURSE
ADD
COURSE #
Payment Method (please mark one):
Check/Money Order #_________
(ex: MATH 1050 Sec 701)
Visa
5-digit Class Nbr #
Master Card
American Express
START DATE
Discover
Please note that all credit card payments will incur a 2.75% credit card processing fee that will appear as a separate charge on your credit card statement.
Print name as it appears on Credit Card
Total amount paid
Signature
Credit Card Number
Exp. Date
I wish to DROP/WITHDRAW from the following course (If past the course census date, a grade of ‘W’ will be recorded on your transcript):
DROP
or
WITHDRAW
TITLE OF COURSE
(if past census
date)
Are you receiving benefits from VA? ___No ___Yes
Was your tuition paid by a third party? ___No ___Yes
Required
Signature
COURSE #
Have you received an award from the UCCS Financial Aid Office? ___No
___Yes
SEC #
CREDIT HRS
START DATE
(For Withdrawals only)
Instructor Signature:____________________________Date:__________
Dean’s Signature:_______________________________Date:__________
I understand that it is my responsibility to know the regulations of the school or college concerning add/drop/withdrawal enrollment and I
accept full academic and financial responsibility for each add/drop/withdrawal. Changes are not official until form is complete and received by
CWES. Any registration after the course Census Date will be charge a $25 late registration fee.
STUDENT’S SIGNATURE:________________________________________________________DATE:__________________________
(FOR OFFICE USE) Date Completed_________
AMOUNT TO REFUND, IF ANY: $________________
ES COORDINATOR SIGNATURE:_______________________________ DATE:______________
updated 1/2014