Person Completing Form
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Phone
*
Email
*
Reason for Membership Change
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Child Lost Interest
Financial
Medical Reasons
Moving Out of Area
Not Getting Any Value From the Program
Unhappy With Staff
Too Busy/Other Activities
Other (Please elaborate in the additional comments)
Family Last Name
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Child(ren) Name(s)
*
Current Membership Level
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Preschool Age
School Age
Other
Date to End Membership
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Cancel Membership
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Yes
No
I understand that by cancelling my membership I will be required to pay an enrollment fee if I decide to return to Alpha Omega.
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Yes
Are you satisfied with the services you received from Alpha Omega?
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Yes
No
Would you recommend our program to a friend?
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Yes
No
Any additional comments or suggestions you would like to give us?
Cancellation Signature
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Clear
Submit