Name of student _________________________ SSN _________________ Phone (_____)_______________

Address _______________________________ City ______________________ State _____ Zip _________

Semester and Year of Academic Suspension:  Fall __________  Spring __________  20_______

The above named student is returning from Academic Suspension and is on academic probation due to failure to maintain the cumulative Grade Point Average required for good standing as shown below:
 

Student's Goal:
_________________________________________________________________________________

_________________________________________________________________________________

Measures student shall take to improve cumulative GPA:
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
 

Schedule of Courses:	Total Semester Hours (Not to exceed 11 hours):
__________________________________	__________________________________
__________________________________	__________________________________
__________________________________	__________________________________
__________________________________	__________________________________

Probation Conditions:

I, ________________________________, understand that I must achieve a 3.0 or better grade point average for this semester or I am subject to Academic Suspension for one term again.  (Withdrawing from ALL courses will also result in Academic Suspension.)

I also understand that these Terms and Conditions of Academic Probation cannot be altered without the written consent of the undersigned counselor and are in addition to the other applicable rules and regulations of the College.
 

_____________________________ Student Signature

____________ Date

_____________________________ Counselor Approval

____________ Date

 

White Copy Director of Counseling

Yellow Copy Student File

Pink Copy Student