Special Circumstance Refund/Credit Request Form
Name on H2O Account
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student's Name
*
First Name
Last Name
Class Registered
*
Payment type
*
Please Select
Monthly Payment Plan
Full Session Payment
Request Type
*
Please Select
Refund
Account Credit
Reason for Request
*
Please Select
Medical Issue
Family Relocation
Other (please explain below)
Explanation of Circumstance
*
Please describe the situation in detail and how it affects your ability to attend.
Date
*
-
Month
-
Day
Year
Date
Acknowledgement
*
I understand that submitting this form does not guarantee a refund or credit. I can confirm that all information provided is accurate to the best of my knowledge.
Submit
Should be Empty: