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Academic Warning Form
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Academic Warning Form
In accordance with the Family Educational Rights and Privacy Act (FERPA), this assessment will be viewed only by your Academic Success Coordinator and Retention Services, and will not be maintained in your permanent student record.
Student Information
Last Name
*
First Name
*
Student ID#
*
Cell Phone
*
Another Contact Phone
Email
*
Major
Do you work?
No
Yes
If yes, how many hours per week?
Do you receive financial aid/scholarships?
No
Yes
Are you a veteran?
No
Yes
What is your educational goal?
Please select all that apply (hold down the CTRL key)
Associate Degree
Certificate
Take courses for transfer to another institution (not seeking AA Degree)
Take courses without working toward a degree, certificate or transfer
Undecided
Why do you think you have not been successful?
Academic Non-Academic
High school study habits didn't work
Health problems
Wait until last minute to do schoolwork
Pressure, stress, anxiety
Late for class three or more times
Transportation problems
Absent from class three or more times
Financial concerns
Class too difficult
Don't like school
Uncertain about major/not sure about career goals
Communication/Language Issues
Changed major one or more times
Other/Explain further:
Other/Explain further:
List 3 ways you plan to improve your academic success:
What campus resources do you think will be helpful?
Please select all that apply (hold down the CTRL key)
LAC tutoring
Academic/Transfer Advising
Career Counseling
Study Skills Assistance
Time Management Assistance
Disability Accommodations
Personal Counseling
Financial Aid Counseling
I understand that I am on academic warning. Being on academic warning affords me the opportunity to work with an academic success coordinator to develop a plan to improve my grade point average. To start on my pathway to success, I need to meet with my academic success coordinator within two weeks of the date on my academic warning letter. Restriction from registering for classes for the next semester will occur if I fail to meet with my academic success coordinator.
My typed name and ID number serves as an authentic signature verifying that the information I provided in this self assessment is accurate.
Student Name
Student ID
