Program Cancellation Request Form

Program Cancellation Request Form
Full Name of Parent or Guardian:*

First NameLast Name
Contact Number:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Student's Name:*

First NameLast Name
Class Day:*
Class Time:
Cancellation for Remainder of Term:*

20% cancellation fee applies without Doctor's noteMedical Certificate supplied
Reason for cancellation:*
Please upload any relevant Medical Certificates:

Upload a File

Cancelof
Please state how you would like your money reimbursed:*

Credit on Links (LLC) account to be used for future programMoney to be reimbursed into your personal bank account (please note if the refund is less than $50, you will be issued petty cash. LLC will contact you to collect):
Please note:

Refunds under $50 will be paid through petty cash. Refunds over $50 are paid via bank transfer.

If the Account Holder Name is different to the name Leschenault Leisure Centre has listed as the "Responsible Person" for the child a phone call will be made to the Responsible Person for verification.
Account Holder Name:
BSB:
Account Number
Bank Name:
Terms and Conditions

Click here to view the LLC Aquatics Terms and Conditions.
I have read and agree with the Terms and Conditions above:*

Yes
Signature*

Clear
Should be Empty: