Student Withdraw Form – Medical Careers Readiness

Medical Careers Readiness Student Withdraw Form

An official withdrawal request form must be completed for students to withdraw. This process can take longer if the student has outstanding fees or school equipment. Upon submitting the request, the student is to return all his/her textbook, and or any equipment. Failure to return items or equipment may delay the withdrawal process.

Date of Birth*

Date of Time*

Name*

Last Name

Address*

City*

State*

Zip Code*

Phone

Email*

Course*

Instructor

First Name*

Last Name*

Terms*

Spring Summer Fall Winter

Evaluation

Complete the section below as it applies. For each statement below, circle the extent to which you disagree or agree with each statement. 1= Strongly disagree 2= Disagree 3= Neutral 4 = Agree 5 = Strongly Agree

Instructor Evaluation

	1	2	3	4	5
The instructor was appropriately respectful of those of us enrolled in this course.
The instructor’s teaching methods assisted me in achieving the course’s learning goals.
The instructor appeared knowledgeable in the subject area.
The instructor encouraged useful participation through discussion and other activities.
The instructor modeled the good thinking, sound judgment, and ethical decision-making.
The instructor presented difficult course material clearly.
The instructor enjoys teaching.
I would recommend this instructor for teaching this course or related courses in the future.

Course Evaluation

	1	2	3	4	5
The course content corresponded well to the course’s stated learning goals.
The course materials and handouts helped me achieve the course’s learning goals.
The way the course was organized facilitated my achieving its learning goals.
The course content was applicable to my own goals for taking the course.
The course was scheduled at day(s) and time(s) that fit well for my other commitments.
The course was intellectually challenging.
I recommend that this course continue to be offered in the future.

Signature of Student/Responsible Party*

Medical Careers Readiness Student Withdraw Form

HENDERSON LOCATION

SCHOOL INFORMATION

BETTER BUSINESS BUREAU

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