Student Name *

First Name

Last Name

Parent/Legal Guardian Name

First Name

Last Name

Will student attend remaining lessons? *

Yes, student will attend remaining lessons

No, student will forfeit remaining lessons

Does student plan to resume lessons in the future? *

Yes, this is a just a break

No, this is a permanent discontinue

Unsure

Acknowledgment of Withdrawal Policy *

I understand that notice to withdraw must be received by the reception desk on or before the 15th. Should notice be given after the 15th, the account will be billed for the following month regardless of student attendance

Electronic Signature *

First Name

Last Name