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Example of Stop Out Form

Example of a Stop Out Form

Parent Promise Scholar Contact Information

Name:

Dallas College Student ID:

Dallas College Campus:

Phone:

Email:

Stop Out Request Information

Date of Stop Out Completion:

Semester of Stop Out:

Anticipated date of return:

Semester:

Year:

Reason for Stop Out Request (check all that apply):

  1. Serious illness (i.e., cancer diagnosis)
  2. Personal accident or injury of a significant nature
  3. Bereavement due to the loss of a close family member - a parent, grandparent, guardian, sibling, son, daughter or a close personal friend. Claims relating to extended family members will not normally be accepted.
  4. Victim of crime
  5. Unforeseen work commitments, not applicable to full-time students
  6. Unexpected pregnancy complications
  7. Jury Service, only if your attendance is compulsory and cannot be deferred

Supporting Documents attached:

  1. Doctor's letter or certificate which confirms your illness and clearly identifies that the time period for which you were unwell corresponds to the assessment period in which you are claiming
  2. Hospital admission and discharge letter, to confirm your time spent in hospital
  3. Death certificate/Order of Service/Funeral Director's Letter
  4. Any supporting statements issued by a Dallas College Campus Personnel i.e., Counselor, tutor must be provided on letterhead paper as a PDF, not a Word document or come directly from the author's email address.
  5. Police report, a crime reference number on its own will not be sufficient
  6. A supporting statement from your employer if your circumstances relate to an unexpected increase in workload or unexpected employment circumstances i.e., deployment. A supporting statement issued by your employer must be provided on letterhead paper as a PDF; not a Word document or come directly from the author's email address
  7. News report to confirm unforeseen transport difficulties

Stop Out Request Information (continued)
Detailed Information from checked responses:





I certify that all provided information is correct and true. I understand it is my responsibility to inform my Success Coach or the Parent Promise Team immediately if there are any changes to my Stop-Out Request.

Signature:

Date:

Success Coach Stop Out Approval/Denial:

  • Approve
  • Deny

Notes:







Success Coach Name:

Signature:

Date: