Boys & Girls Club of Clifton

Boys & Girls Club of Clifton
Request to Remove from Program
Remove my child(ren) from the following program:
Remove from program effective:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name:

First NameLast Name
School:
Child's Name:

First NameLast Name
School:
Child's Name:

First NameLast Name
School:
Child's Name:

First NameLast Name
School:
Child's Name:

First NameLast Name
School:
Are you enrolled in Auto-Pay?
Overpayment Options
I am requesting to withdraw my child(ren) from the program effective on the date indicated above. I understand that I am required to provide 30 days' notice and that I am responsible for payment of any outstanding tuition or fees. I understand that my deposit will be applied toward my child(ren)'s final month of programming.

I also understand that if I wish to re-enroll my child(ren) in the program in the future, placement will be subject to availability, and my child(ren) may be placed on a waiting list if no space is available.
Parent Name:

First NameLast Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: