Graduate Merit Scholarship Petition

Please complete this form in the event that you have lost your scholarship or anticipate a change in your circumstances that could result in the cancellation of funding based on the terms of your award.

Name Name First Last
Email
Phone Phone - ### - ### ####
I know my Simmons ID number:

I know my Simmons ID number: Yes No
Simmons ID
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Program Information
In which semester did you begin attending Simmons?

Ex: Fall 2018 or Spring 2019
Do you attend a traditional, on-campus program or an online program?

Do you attend a traditional, on-campus program or an online program? Traditional On-Campus Program Online - Library Science or Nutrition Online - All Other Programs
***Do not continue***

Please exit this page without submitting and contact your Student Support Specialist for further assistance. This form is intended only for students enrolled in a traditional, on-campus; an online library science program; or an online nutrition program. Petitions submitted by students in our other online programs cannot be processed using this form.
What subject best describes your field of study and the degree you are pursuing?

What subject best describes your field of study and the degree you are pursuing? Social Work Nursing Physical Therapy Nutrition Public Health Behavior Analysis Education History Public Policy Gender and Cultural Studies Children's Literature Library and Information Sciences Other (Please specify - including Dual Degrees)
Appeal Scenario
What best describes your current situation?

What best describes your current situation? I plan to reduce my enrollment in a future semester and would like to discuss the impact on my scholarship I was notified I no longer qualify for my merit scholarship - due to enrollment or GPA - and would like to appeal this decision
Intended Enrollment

Please indicate your anticipated enrollment for the following terms in the current academic year:
Summer

Summer I have enrolled/intend to enroll I do not plan to enroll

Note: If you are currently enrolled in or have completed a term listed here, enter the actual number of credits you were/are taking
Number of credits:
Fall

Fall I have enrolled/intend to enroll I do not plan to enroll

Note: If you are currently enrolled in or have completed a term listed here, enter the actual number of credits you were/are taking
Number of credits:
Spring

Spring I have enrolled/intend to enroll I do not plan to enroll

Note: If you are currently enrolled in or have completed a term listed here, enter the actual number of credits you were/are taking
Number of credits
If you have already met with your advisor, please indicate your enrollment plans for the remainder of your program. This information will be required to determine future eligibility for scholarship funding.
For example: Fall 2019 - 8 cr; Spring 2020 - 8 cr; Summer 2020 - 4 cr; etc. Maximum of 200 words allowed. Currently Entered: 18 words.
Special Circumstances

Please select one option that best describes why you have not met/will not meet the requirements to maintain eligibility for your scholarship as outlined in your acceptance letter.
I have recently experienced:

I have recently experienced: Health related issues (family or your own) Unexpected financial difficulties A change/conflict with work Military deployment Personal/Other problems
Please briefly describe your circumstances.
Maximum of 200 words allowed. Currently Entered: 0 words.
Attach Additional Documentation

Attach Files

If you would like to provide additional information, please attach it here. For example: a letter, doctor note, etc.
Signatures and Certifications

Please read this section carefully.
Please acknowledge by checking each box.

Please acknowledge by checking each box. I understand that by signing this form that all information provided is complete and correct to the best of my knowledge. I understand if I do not notify SFS of changes to my enrollment, my actual enrollment will be reviewed at the end of the add/drop registration period and my financial aid will be adjusted at that time, if necessary. I understand that the submission of this form does not guarantee that my scholarship will be reinstated or redistributed.
Student Name
Today's Date Today's Date / MM / DD YYYY
Student Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Type the letters you see in the image below.

Graduate Merit Scholarship Petition

Graduate Merit Scholarship Petition

Program Information

Appeal Scenario

Intended Enrollment

Special Circumstances

Signatures and Certifications