APPEAL
Request for Exception to College Policy
This form must be completed in full and signed by the student to be considered for an
exception to college policy. You must submit all supporting documentation with this
request and write a statement on the reverse side
No appeals will be accepted for situations that occurred after the 12th week of the semester for 16-week classes, or after
the 6th week for 8-week classes.
Appeals requested for medical reasons must include information obtained from a professional. The information must be
submitted on physician’s letterhead along with this form, and must include the following: Physician’s name, contact
information and signature; date of onset and duration of illness; problem/issue/diagnosis; and date student was/will be
capable of resuming academic studies.
Appeals regarding a course instructor, course content, grade or other concerns of an academic nature must be submitted to
the appropriate instructor/department.
I have read and understand the above information. If this appeal pertains to requesting a refund for a class, I have
taken responsibility to drop the class (es) in the Enrollment Services department. I have included all necessary
documentation to support my claim.
Signature
Date
Name (Printed)
Semester & Year
Address
Phone Number
City, State, Zip
Student # X
How was tuition paid?
Birthdate
Pell Grant
Voc. Rehab.
Paid own tuition
Other:
Tuition has not been paid
For Office Use Only: Date Approved
Total credits enrolled for
Total credits dropped
Date of withdrawal
(if applicable)
Date
Denied
Date Student Notified:
Comments and/or Reason for Denial:
Staff Signature
Date
Return completed appeal to the StarZone, located in the Gannon Building on the 2nd floor or by mail to:
1121-Admissions, Registration & Records
Lansing Community College
P.O. Box 40010
Lansing, MI 48901-7210
(over)
Statement of Appeal
Please explain briefly but completely the reason for your appeal.
Signature:
Date:
Submit this form to the StarZone, located in the Gannon Building on the 2nd floor. Remember to include any
documentation that may be needed. Your appeal will be reviewed and you will be notified of the decision in
writing in 4-6 weeks.