Madison College Extenuating Circumstance

If situations outside of a student's control requires them to drop their classes and temporarily postpone their academic
career, the student may apply for a possible partial refund of tuition.
At the time of an extenuating circumstance, students are encouraged to work with their instructors to see if arrangements
can be made to complete class work.
MADISON COLLEGE
Extenuating Circumstance
14Feb2014
Death of an immediate family member.Offcial death certifcate is required.
Medical emergency for self or dependent. Please have the patient's medical provider complete the attached
Medical Documentation form.
Unscheduled Guard/Reserve obligations that prevented attendance for an extended period of time.
Signed notifcation, including the duration of the obligation, is required.

Financial Aid: Students who received fnancial aid and were granted an Extenuating Circumstance may still need
to complete the fnancial aid appeal process. More information can be found at madisoncollege.edu/appeal-process.
Veterans Benefts: If the student is receiving veterans educational benefts, an Extenuating Circumstance refund may
result in repayment. Veteran students who have been called to active duty must also submit a Military Activation/
Deployment Checklist. More information can be found at madisoncollege.edu/military-activation.
Health Insurance: If the student is on a health insurance plan (parents or other) that requires active enrollment, please
research possible impacts of a withdrawal.
EXTENUATING CIRCUMSTANCE MAY CONSIST OF THE FOLLOWING:
POSSIBLE IMPACT RESULTING FROM A GRANTED EXTENUATING CIRCUMSTANCE:
Past Due Account Balance - Students submitting an Extenuating Circumstance are still responsible for past
due account balances while the request is being reviewed.
Failure to Drop Classes - An Extenuating Circumstance can only be granted to classes that were dropped
prior to the 90% point.
Non-attendance and/or Poor Academic Progress - Extenuating Circumstances are for those students who are
academically engaged (attended and participated in classes until the extenuating circumstance occurred).
Situations that are Academic in Nature - If the situation is related to coursework and/or instruction, please refer
to Student Conficts, Complaints and Concerns at madisoncollege.edu/student-concerns.
Failure to Receive an Invoice - It is the responsibility of the student to keep contact information current in their
myMadisonCollege Student Center. Students must pay tuition and fees by the due date stated on their invoice.
THE FOLLOWING ARE NOT GROUNDS FOR AN EXTENUATING CIRCUMSTANCE:

An Extenuating Circumstance application must be completed by the student. The completed Extenuating
Circumstance application with proper documentation must be submitted to the Enrollment Center no later than 30
calendar days (postmarked) after the end of the term.
Submit completed form and documentation in-person to the Enrollment Center - Truax, Room A1000, or Enrollment
Center - Downtown Campus, Room D117; or submit by mail or fax to:
Address:

Enrollment Center

Fax:

(608) 243-4353

Madison College
1701 Wright Street
Madison, WI 53704

Please allow up to 60 days to research and process an Extenuating Circumstance application. Applications are
reviewed in the order they are received. Any determinations will be communicated via paper letter to the mailing
address provided.
INSTRUCTIONS:
If you have already been granted an Extenuating Circumstance, you are not eligible to submit another request.
Questions? For further assistance with this form search FAQs or submit a Records category question on askMadisonCollege or

contact the Enrollment Center at (608) 246-6210.
Past due balances restrict course registration. Students must pay past due balances in order to register for future
classes while the Extenuating Circumstance is reviewed.
Inability to pay/job loss. Course registration creates a fnancial obligation to Madison College.
Transportation issues. Students are responsible for transportation to and from class.
Please attach supporting documentation and indicate why you feel you qualify for an Extenuating Circumstance (you may use
additional paper and attach):
INSTRUCTIONS - Submit completed form with supporting documentation by mail to Enrollment Center, Madison College, 1701
Wright Street, Madison, WI 53704, or by fax to (608) 243-4353. For assistance, contact the Enrollment Center at (608) 246-6210.
Results sought and future academic plans:
I understand that failure to supply truthful, adequate and complete information on this application or supporting documentation will
result in a denial of the request with no further rights to appeal.
Were you working at the time? Were you able to continue your employment?
MADISON COLLEGE
Extenuating Circumstance Application
Name
Student ID or Social Security Number (required) Email
Phone
Mailing Address (Street, Apt., City, State, Zip)
Did you receive fnancial aid for the identifed term? Yes No
Term Fall Spring/Interim Summer
Academic Year
Did you receive veterans benefts for the identifed term? Yes No
Class Number
(5 digits)
Class Title Meeting Day/Time
Last Date of
Attendance
Did you notify the
instructor?
Did you discuss your situation with college instructors, advisors or staff? Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Date(s) that you dropped your classes and confrmation numbers received:
If yes, please describe. If no, indicate why:
No Yes No Yes
14Feb2014
Student Signature ____________________________________________________________________ Date ____________________________________
Enrollment Center - Records Use Only:
Staff Name _________________________________________________________ Staff Title _______________________________________________ Date Processed _____________________________
Power of Attorney Name
Or: Power of Attorney Signature*_____________________________________________________ Date ____________________________________
*Requests from a power of attorney require legal documentation
of possession of power of attorney at the time request is submitted.

Please drop the student from the classes
below, effective today.
REQUESTS DUE TO MILITARY ACTIVATION ONLY:
CLASS INFORMATION
STUDENT INFORMATION
REASON FOR EXTENUATING CIRCUMSTANCE
Name
Your patient (or patient's guardian) is a student at Madison Area Technical College who is applying for an Extenuating
Circumstance that may result in a partial refund of their tuition due to circumstances beyond their control.
A qualifying Extenuating Circumstance is only for a medical emergency that resulted in the patient being advised not to attend
school for an extended amount of time.
Please fax completed form to the Enrollment Center at (608) 243-4353. For assistance, contact the Enrollment Center at (608)
246-6210.
Student ID or Social Security Number
By signing below, you are attesting that the patient was seeking and receiving the proper care, following the proper protocol and
medical provider's orders, and was in no way able to attend and/or participate in classes during the duration noted above. You
may be contacted for additional information.
To be completed and signed by a licensed healthcare professional who diagnosed and treated the patient.
Was the patient admitted into the hospital? Yes No
If yes, give dates:
Was the patient (if the student) advised not to work? Yes No
If yes, give dates:
Was the patient (if the student) advised not to attend school?
If yes, give dates (REQUIRED):
Was the patient following all recommended course of treatment(s)?
What was the diagnosis and what impact did it have on his or her ability to carry out their job responsibilities or school work? For pre-
existing conditions, please describe the changes that occurred within the term which prevented attendance of classes.
Name Title
Organization Phone Number
Is the student the patient or guardian of the patient? Patient Guardian
If guardian, please state relationship to patient:
If no, please describe:
MADISON COLLEGE
Extenuating Circumstance - Medical Documentation
Yes No
Yes No
Signature ___________________________________________________________________ Date ____________________________________________
14Feb2014
Questions? For further assistance with this form search FAQs or submit a Records category questions on askMadisonCollege or
contact the Enrollment Center at (608) 246-6210.
Date of initial diagnosis: Date of initial appointment:
Dates of follow-up appointments:
Enrollment Center - Records Use Only:
Staff Name _________________________________________________________ Staff Title _______________________________________________ Date Processed _____________________________
HEALTHCARE PROVIDER INFORMATION
STUDENT INFORMATION
INSTRUCTIONS
SIGNATURE & AGREEMENT
Is the patient or guardian able to return to school? No Yes

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If situations outside of a student's control requires them to drop their classes and temporarily postpone their academic

THE FOLLOWING ARE NOT GROUNDS FOR AN EXTENUATING CIRCUMSTANCE:

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