Form to Decline the Right to Perform a Rewrite  

STUDENT NAME: ______________________________________________________ 

PROGRAM: ________________________ DATE: _______________________ 

COURSE: ___________________________           INSTRUCTOR: _______________ 
 

DISCUSSION: 
 
 
 
 
 

ACTION: 

• I, ________________________, have declined to take the ______________________________________________ re-write.
• I understand that I must achieve an overall grade of 70% or greater to pass this course.  If my final overall grade is less than 70%, I am fully aware that I may not re-write the above exam/assignment to try to better my final overall grade.
• I understand that if I fail any one course (receive lower than 70% overall) within my program, I will not be eligible for placement on practicum, and will not be eligible to graduate with my class. I would have to wait and retake the course (a maximum of one) with a future group (space permitting).  If I fail a “core” program course, I will not be able to continue onto the next course, i.e. if I student failed the medical terminology course, I would not be eligible to move forward and take the anatomy and physiology course. 
• As of this date ______________________________________, the re-write option is no longer available to me.

Student Signature: ____________________________________________   Date: ___________________ 

Authorized Signature: _________________________________________   Date: ___________________

Original – Student     Copy - File