Program Withdrawal Request Form

Program Withdrawal Request Form

Kumon Center of Hollywood, FL / 3315 Sheridan Street Hollywood FL 33021
Student Name*

First NameLast Name
Parent Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent Name*

Reason For Cancelling

CityState / Province

Postal / Zip Code
Reason for stopping Kumon*

Reason For Cancelling

CityState / Province

Postal / Zip Code

Policy Details
I wish to cancel: (select one)*

Math OnlyReading OnlyMath and Reading
Desired Cancellation Date (30-day notice required)*

MonthDayYear
A 30-Day notice policy means that termination will take effect at end of the following month that the request was submitted.
I am requesting the cancellation of the Kumon Program on the date specified.

I understand that the Kumon Center of Hollywood, FL requires a 30-day notice for cancellations. Therefore, I am still responsible for 1 more tuition payment after submitting this request. My program will end at the end of next month.

I understand that you may need to contact with me to verify my cancellation request. I also understand that you may have further questions, so I am giving my consent to your company representatives to contact with me via phone or email.
Today's Date*

MonthDayYear
Date
Parent Signature*

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