Course Withdrawal Form

Important Information

This form should only be submitted to withdraw after the first day of the course. Please see the withdrawal policy for applicable withdrawal and refund deadlines in the Distance Learning Course Schedule.

There are potential academic and financial consequences related to the Charter Oak State College Withdrawal Policy. For each course you withdraw from, a grade of ‘W’ will be entered into your permanent academic transcript. To receive a grade of "W," you must withdraw from each course by the withdrawal deadline date for that term as stated in the Course Schedule. Students seeking a degree at COSC should discuss their particular situation and potential implications with their Academic Advisor. Students receiving Financial Aid should contact the Financial Aid office. Non-Charter Oak State College students should contact their home institution.

* These fields are required.

Student Information

COSC Email*:

Semester*: Year*:

COSC Student ID Number*: (i.e., 123456)

Last Name*:

First Name*:

Middle Initial:

Address Line 1*:

Address Line 2:

City*:

State*: Zip Code*:

Daytime Phone:

Evening Phone:

Course Information

(All courses with "‡" in the drop-down menus below do not qualify for refunds.)

Course #1*:

Course #2:

Course #3:

Course #4:

Reason(s) for Withdrawing*:

Have you sent assignments to your instructor?

Have you contacted your instructor?

Payment Information

Refunds are given only during the refund period stated in the course schedule.

I am receiving federal financial aid.* [Required Field]

I originally paid for this course with*: [Required Field]
If "Other," please specify here:

(If renting video tapes or DVD's, please return them to avoid additional charges.)

I understand that I am responsible for making remaining course payments not covered by any refunds due to me.

If you have any questions related to the this withdrawal form, please e-mail dlinfo@charteroak.edu.