Private Lesson Withdrawal Form

Student #1 Name:

First Name

Last Name

Student #2 Name:

First Name

Last Name

Parent/Guardian Name (if minor):

First Name

Last Name

Email:

Phone:

(###)

###

####

Teacher Name:

Primary Lesson Location:

Current Lesson Day & Time:

Ex: Tuesdays 4-4:30pm

Today's Date:

YYYY

Withdrawal Effective Date:

YYYY

Withdrawal Type:

Standard (form submitted by 15th of previous month)

Expedited ($60 processing fee to begin withdrawal the following month)

Reason for Withdrawal:

Additional comments or feedback for your teacher or the studio:

I understand this form must be submitted by the 15th of the month in order not to be charged on the 1st of the following month. For example, to discontinue lessons beginning July 1st, your withdrawal form must be received by June 15th. If your form is submitted after the 15th of the month, you may opt to withdraw beginning the following month by paying a $60 expedited processing fee per student.

By typing my name below, I am electronically signing this notice.