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:
Reason for cancellation:
Please upload any relevant Medical Certificates:

Upload a File

Cancelof
Please state how you would like your money reimbursed:
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:
Signature
Privacy Collection Notice: The Shire of Harvey collects personal information to respond to enquiries and deliver services. Information is managed in accordance with applicable legislation and may be disclosed where authorised or required by law. For further information, visit the Collection Notices page .
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