Nursing Programs Withdrawal and Exit Interview

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Cancellation, Withdrawal, and Failed Course Refund Policy and Procedure
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Student Name* This field is required.
First Name
Last Name
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Student Email* This field is required.
example@example.com
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Program* This field is required.
Please Select
Please Select
ADN Program
RN to BSN Program
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In which ADN semester are you currently enrolled and withdrawing?
Please Select
Please Select
Semester 1 (NURS100: Fundamentals)
Semester 2 (NURS110OB, NURS120P, NURS130MS)
Semester 3 (NURS210BH, NURS220G, NURS230MS)
Semester 4 (NURS240: Advanced Med Surg)
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Do you wish to withdraw from the entire RN to BSN Program, or are you wanting to pause the program by dropping specific courses?
I wish to withdraw from the entire program
I want to pause the program by dropping specific courses
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Which RN to BSN course(s) are you withdrawing from? (Select all that apply)
NURS310
NURS320
NURS330
NURS340
NURS410
NURS415
NURS420
NURS430
NURS440
NURS445
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Date of Last Attendance* This field is required.
Date
Month
Day
Year
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Please sign below that you understand dropping these courses will delay your program completion date and, therefore, your projected graduation date.
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I have read and understand the Cancellation, Withdrawal, and Failed Course Refund Policy and Procedure and my signature below signifies my formal request to withdraw from the program listed above. I also understand that to re-enroll in the program, I may be required to accept a difference in tuition (either greater or lesser), may not be guaranteed a seat in the next cohort, and may be required to complete additional documentation or tasks (i.e. meetings) to ensure readiness for the program.
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Select all of the following that contributed to the unsuccessful completion of this program or course(s):* This field is required.
Financial issues
Time commitment issues
Personal issues
Prefer not to say
Other
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Please explain your reasoning for the above selection:* This field is required.
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Did you utilize faculty office hours?* This field is required.
No, not at all
Less than 5 hours
5-10 hours
More than 10 hours
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Did you utilize support from Director of Nursing or Assistant Director of Nursing?* This field is required.
No, not at all
Less than 5 hours
5-10 hours
More than 10 hours
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Did you utilize support from Dean of Nursing or Dean of Educational Services?* This field is required.
No, not at all
Less than 5 hours
5-10 hours
More than 10 hours
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Please explain your reasoning for the above selections:* This field is required.
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Did you apply for and receive accommodations in the WALT?* This field is required.
Yes
No
N/A
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What changes would you recommend to promote success moving forward? * This field is required.
Should be Empty: