College Grade Appeals / Dismissal Intake Form

Student Name

First Name

Last Name

Year in School

e.g. sophomore or professional school or PhD candidate

Home Address

Phone

(###)

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Student's Personal Email

Student's School/University Email

Parent Name

Name of parent /guardian if involved

First Name

Last Name

Parent's Email

If parent is involved

Parent's Phone

If parent is involved

(###)

###

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Referral Source

Adverse Parties

Name of College / University Attending / Program

Has a Hearing Been Scheduled or Already Held?

Dates of Any Hearings (Either Held or Scheduled)

Brief Description of What Happened