Class Withdrawal Form

Class Withdrawal Form
FAMILY INFO
Last Name
Mother / Father Name
E-mail
Main Contact

Area CodePhone Number
STUDENT INFO
1st Child
Birthdate

MonthDayYear
Gender
2nd Child
Birthdate 2

MonthDayYear
Gender 2
3rd Child
Birthdate 3

MonthDayYear
Gender 3
4th Child
Birthdate 4

MonthDayYear
Gender 4
CLASS WITHDRAWAL

Please note: withdrawals requests made after the first of a month, will have payment stop the following month.
Effective Month
Effective Year
Student
Name
Class hidden
Class
enter name of class
Student 2
Name
Class 2
enter name of class
Class 2 hidden
Student 3
Name
Class 3
enter name of class
Class 3 hidden
Student 4
Name
Class 4
enter name of class
Class 4 hidden
Reason for Withdrawal
Please discontinue automatic payments to my credit card on file. I understand that my child's spot in that class is no longer held once I withdraw.
My signature indicates my (our) agreement with the withdrawal policy
Date

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