We are sorry to see you go! Please use this form to withdraw from classes.

PLEASE REMEMBER

There are no refunds for tuition payments already made, regardless if the classes were attended.
Withdrawal is due by the 20th of the previous month to avoid being responsible for the next month's payment.

Student Name

First Name

Last Name

Lesson Day/Time

Withdrawal Date

I am withdrawing from lessons at Piano Tunes Music Academy effective (date.)

YYYY

Why are you withdrawing from lessons?

Lost interest

Financial issues

Too busy / scheduling problems

Unhappy with teacher / lessons*

Other

*If you are unhappy with the classes, can you tell us your problems and concerns?

If you were unhappy with the teacher, would you like a demo lesson with a different teacher?

Yes

Not applicable

Any other feedback for us?

Name of Parent/Guardian

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country