Academic Review Board Appeal Form-Graduate Students

1. Name (Last, First) *This question is required.

2. Title and Pronouns (in what way would you prefer to be addressed?) *This question is required.

3. Relay Student ID Number *This question is required.

4. Preferred Email Address This question requires a valid email address.

5. Advisor Name *This question is required.

6. Advisor Email Address This question requires a valid email address.

7. Please list all the names of your Professors from this term. *This question is required.

8. Please share the reason for your dismissal:

9. Why are you seeking to appeal this dismissal? What were the major factors that contributed to your dismissal from Relay? *This question is required.

10. If your petition to appeal is approved what steps will you take to address the factors that contributed to the dismissal, to ensure your future success? Who (beyond Relay faculty) could support you in your success? When and how would you reach out to them for this support? *This question is required.

11. Optional: What additional information or artifacts would you like to include to support your petition?

12.

By typing your name and the date below, you are confirming the following:

You wish to petition to have your dismissal appealed
You have spoken to your academic advisor about your academic standing
You have completed each section of this form to be emailed to studentaffairs@relay.edu

Additionally, you confirm that you understand the following:

While you await your decision (within 10 business days), you should still attend and participate in coursework as you are considered an actively enrolled student.
If your appeal is denied, you will not earn credit for current coursework; however, you will also not be charged for your participation.

*This question is required.

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