CSA Withdrawal Form

CSA Withdrawal Request
Have you spoken to your CSA instructor about this withdrawal?*

YesNo
If you have not spoken to your teacher about your intent to withdraw, please do so before submitting this form. Your request to withdraw will not be processed until you have spoken to your teacher.
CSA Student Name*

First NameLast Name
In the rare case of multiple students (i.e. family moving away), write all names here. Please be sure to speak to all involved teachers first.
Parent Name (if adult student, write "n/a")*

First NameLast Name
E-mail*
example@example.com
Program(s) from which to be withdrawn:*

Early Childhood ClassPrep LessonsMusic Makers at the Keyboard ClassSuzuki LessonsBeethoven's Buddies LessonsOther
Reason for withdrawal (please be as specific as possible):*
Date for withdrawal to take effect (must be future; if ASAP, choose today's date):*

MonthDayYear
Date
Do you hope/plan to return to CSA in the future?*

YesNoNot sure
Is there anything CSA could have done differently that would have kept you from withdrawing at this time?*
Please feel free to leave our office any other comments.
CSA Withdrawal Policy:
A $35 cancellation fee will be assessed for students who enroll and subsequently withdraw prior to the first class.

A student who withdraws during the first four weeks of the semester will be charged for the weeks prior to withdrawal, plus 50% of the semester’s remaining tuition.

For a withdrawal after week four of the semester there is no tuition refund except in the case of serious illness or relocation, the final determination of which shall be made by CSA.

By signing below, I confirm that I have read this policy and understand that I must pay my CSA bill in full before my withdrawal will be complete.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Would you like someone in the office to contact you regarding your final CSA bill?*

Yes, please send me a final bill using the email address listed aboveYes, please call me at the phone number above to discuss my final billNo, I know how much I owe and will pay it ASAP
If you would like to speak further about your experiences at CSA, please contact:

Deborah Klemme, Director
(630) 752-5814
deborah.klemme@wheaton.edu

We thank you for your investment in the CSA and wish you all the best!
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CSA Withdrawal Request