Withdrawal Request Form

Withdrawal Request Form
Every withdrawal situation is different, and Bloomingdale will work to find an adequate and rapid solution to each case. Students who wish to withdraw must fill out this withdrawal request form. Please submit one request form per student.

Once this form is received, a BSM staff member will contact you at the email address provided to confirm the cancellation of your lessons and payment plan. Please note your withdrawal is not complete until confirmed by a staff member. If you have any questions, please contact the office at registar@bsmny.org or 212-663-6021.

To view our registration and withdrawal policies, please click here.
Student & Class Information
Name of student withdrawing:*

First NameLast Name
Name of parent/caregiver (if applicable):

First NameLast Name
Email Address:*
example@example.com
Date of Request:*

MonthDayYear
Date
Semester from which you are withdrawing:*

FallSpringSummer
Is this a medical withdrawal?*

YesNo
Bloomingdale School of Music offers medical withdrawals with refunds or credits on a case by case basis with a doctor’s note. Basis for withdrawals include injuries or illnesses that genuinely impede a student’s abilities to successfully participate in their musical instruction or instrument learning.

Credits & Refunds
Are you interested in transferring to another teacher's studio or exploring other class options at this time?*

YesNoOther
Please select the type of enrollment from which you are withdrawing:*

Private lessonsGroup class
All group class withdrawals must be submitted at least 24 hours prior to the day and time of the third class of the semster.
All private lesson withdrawals must be submitted at least 24 hours prior to your next scheduled lesson. Private lesson withdrawal requests made with less than 24 hours notice will be responsible financially for the cost of the lesson and if missed, the lesson will not be eligible for a makeup lesson.
Class/lesson from which you are withdrawing (example: 30 minute Violin lessons, Guitar for Children, Jazz Ensemble, etc)*
*Please note, group class withdrawals must be made at least 24 hours prior to the third class of the semester
Briefly explain the reason for your requested withdrawal:*
Please select which you would like to receive:*

CreditRefund
Please note, all credits are valid for up to one year from the date issued and may be used for any offering during any semester.
Please note, private lesson refunds have a penalty equal to the cost of two lessons withheld. There is no penalty for a credit withdrawal.

Medical Withdrawals

Bloomingdale School of Music offers medical withdrawals with refunds or credits on a case by case basis with a doctor’s note. Basis for withdrawals include injuries or illnesses that genuinely impede a student’s abilities to successfully participate in their musical instruction or instrument learning.
Please attach a doctor's note:

Cancelof
Class/lesson from which you are withdrawing (example: 30 minute Violin lessons, Guitar for Children, Jazz Ensemble, etc)*
*Please note, group class withdrawals must be made at least 24 hours prior to the third class of the semester
Please select which you would like to receive:*

CreditRefund
Please note, all credits are valid for up to one year from the date issued and may be used for any offering during any semester.
Please note, all withdrawals must be submitted at least 24 hours prior to your next scheduled lesson or class. Withdrawal requests made with less than 24 hours notice will be responsible financially for the cost of the lesson and if missed, the lesson will not be eligible for a makeup lesson.

Exit Survey

We'd love to learn more about your experience at Bloomingdale so that we might improve our offerings in future semesters.
Are you interested in returning to BSM for future semesters?

YesNoOther
Would you recommend BSM to others?

YesNo
Please explain:
How can we improve our services and/or programs to better serve your music education needs?
Thank you for choosing BSM for your music lessons. We appreciate your feedback and hope to see you return soon.

Please click "submit." Once this form is received, a BSM staff member will contact you at the email address provided to confirm the cancellation of your lessons and payment plan. Please note your withdrawal is not complete until confirmed by a staff member. Thank you for choosing Bloomingdale for your music education needs. We appreciate your feedback.
Should be Empty:

Student & Class Information