Al-Ihsan’s Course Withdrawal Request Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Course/Program Enrolled:(Required)

Reason for Withdrawal(Required)

(Please select one or more)

Financial Difficulty

Scheduling Conflict

Commitment Issue

Health/Personal Reasons

Dissatisfaction with course

Other (please specify below):

Possible Solutions(Required)

(Please let us know if any of these options might help you continue enrollment):

Payment Plan/Financial Aid

Extra Academic/Learning Support

Temporary break/pause in enrollment

Other (Please specify below):

Withdrawal Effective Date:(Required)

MM slash DD slash YYYY

Overall Course Experience:(Required)

How would you rate your experience in this course?

General Feedback/Comments

Signature

Δ