Date form

Application for Withdrawal from received by CAS Academic Registry

Hub:
Study Click or tap to Rev –Feb
enter a date.
Taught Students 2019

This form is specifically for those Students at UCLan Partner

Institutions in the UK and Overseas
Before you Withdraw

o Think about your options and seek help as early as possible to ensure you are informed about the
consequences of what you plan to do. You should note that Withdrawal from Study means permanently
ceasing your studies and the process may affect both your accommodation, your tuition fees and any
other related fees. The University is keen that you continue with your studies if you possibly can.
o Consider an Interruption to Study or a Course Change and seek guidance or advice from your
Authorising Officer. Also consider seeking advice concerning accommodation, benefits and funding from
your Authorising Officer or local advice centre. Withdrawal from Study means that you have decided to
permanently discontinue your current course of study with no intention of resuming.
o If you have made a final decision to withdraw permanently from your studies, you must let us know
formally through completion of this form of what you are intending to do as soon as possible. Failure to
inform UCLan in this way will mean that
o Your Tuition Fee Liability will continue to accrue
o UCLan will not be able to promptly notify the Student Loan Company or other relevant
bodies of any changes in your circumstances.
How do I apply to withdraw from study?
1. Seek guidance on the application process from your Authorising Officer/local administrator
and complete Section 1 with your details.
2. Contact your Authorising Officer and arrange to meet with them in person, via
Skype/Facetime or telephone to formally discuss your request. Once you have met with your
Authorising Officer you are strongly recommended to seek guidance from your local Advice Centre
on the financial implications of your withdrawal.
The Authorising Officer may, if you are in agreement and if practicable, be able to facilitate a phone
call between yourself and your local advice centre during your meeting.
Students are also recommended to seek advice on benefit entitlement and Council Tax exemptions
where relevant.
3. Read through the declaration in Section 2, sign the form and submit to your local
Administrator who will forward to your CAS Hub for processing.

Section 1: Your details For student completion only

Surname: de Moura Vommaro First Name(s): Leonardo Francesco
G21294205
Registration No: Partner Institution/Campus: UCLan London
Please indicate if you are:
Date of Birth: 27/08/2001
Home: ☐ EU: ☐ Overseas/International: ☐
Psychology
Course Name: Year of Course: Year 0
Mode of Attendance: I am a sponsored student: Yes: ☐ No: ☐
Full-Time: ☐ Part Time: ☐ Sandwich: ☐ Distance Learning: ☐
Section 2: Student Declaration For student completion only
 I note that withdrawing from my course of study at UCLan may affect my eligibility for full-time or
part-time financial support, the funding package for which I am eligible and the tuition fees charged and that it
is recommended that I seek advice from the UCLan Student Union regarding the wider financial implications.
 I am aware that all guidance is provided in good faith based on the information held about my
situation. I note that UCLan endeavours to ensure that guidance is accurate at the time it was given. However,
it can be subject to change and responsibility cannot be accepted for any errors or omissions, for
consequences arising from the use of the information, nor for decisions or updates made by government
agencies. Should any information change, any guidance that I have already been given may no longer be
applicable and I may be required to /the local advice centre.
 In submitting this form, I confirm that I have investigated my circumstances in light of the changes
requested above and understand the impact upon my academic studies.
Leonardo Francesco de Moura
Signed:
Vommaro
Date: 19/01/2025
Please now submit this form to your local administrator within 2 working days of your meeting with your
Authorising Officer.

Section 3: Authorising Officer Approval For Authorising Officer completion only

NB: Authorising Officer to complete this section and return form to student.
Date of Withdrawal:
I.This is the date of the meeting with the Authorising Click or tap
I authorise this Student’s withdrawal from
Officer to enter a
study ☐ II. Retrospective withdrawals are not normally date.
permitted, seek guidance from SRMTeam
I confirm that the student has either already received financial and/or immigration advice (as part
of a meeting with me) or has been advised to subsequently obtain this from the local advice ☐
centre.
Click or tap to
Print Name: Date:
enter a date.
Could the Partner Institution have done anything to prevent this Student leaving? Yes: ☐ No: ☐
With electronic completion, this is an expandable text
If yes, please specify:
field

With electronic completion, this is an expandable text
Outline reasons for the Student’s withdrawal:
field

Main reason for withdrawal – select only If there is more than one reason, please choose the most appropriate/significant
one: option
a. Transferring to another i. Chose the wrong course for me: ☐
institution: ☐ j. This was not my first choice of course: ☐
b. Health issues: ☐ k. The level of access to University support services:
c. Financial reasons: ☐ ☐
d. Going into employment: ☐ l. The levels of provision of specialist equipment for the
e. Travel difficulties (cost/time): ☐ course: ☐
f. Problems with m. The level of provision of library/computing resource
accommodation: ☐ facilities: ☐
g. Level of access to study support: n. The way the course was taught and assessed did not suit
☐ me: ☐
h. Needs of dependants/childcare o. The level of provision of social facilities: ☐
issues: ☐ p. Other personal reasons: ☐

For Registry Internal Processing only

Section 5: Notification of Student Withdrawal For CAS Hub completion only
Student Support No: UCAS Code: (if known)
Reported when students who have declared a disability withdraw Yes No
([email protected]) or where a withdrawal is related to wellbeing or welfare
 matters ([email protected])?
If appropriate, has the Accommodation Office been informed
Yes No
([email protected])?
CAS Hub Declaration: I confirm that I have processed the above Interruption to study as detailed, updated the
Banner Student Record system as appropriate, sent this form to [email protected] copying in other
appropriate teams as detailed above.
Name: Date: Position:

Fee adjustment details: 2 Portal 3 Other Comment For SFFT completion only
Original Fee: Revised Fee:

Comments: Pending
Submitted

Staff initials and date

Staff initials and date Staff initials and date