ELCA After-School Program WITHDRAWAL FORM

ELCA After-School Program

WITHDRAWAL FORM
Student's Name:*
Grade:*
Homeroom:*
I wish to withdraw my child from the ELCA After-School Program as of
today. The weekly cost of the program will no longer be billed to my
account.
Parent Signature*

Clear
Date*

MonthDayYear
Date
Reason for withdrawal:*
The ASEP program is perpetually billed weekly regardless of hours or days
attending until and unless a withdrawal form is received. Students who withdraw
from the program and later re-enroll will incur a $30 re-enrollment fee.
Should be Empty: