Student First Name *

Student Last Name *

Parent First Name

Parent Last Name

Email *

Classes You Wish To Drop *

Reason For Dropping *

If we could have done one thing differently to keep you, what would it have been? *

On a scale of 1–10, how likely are you to recommend Alta Loma Dance Academy to a friend? *

Please note, a signed and completed request must be received & confirmed by the 15th of the month to avoid being charged tuition on the 1st.

If notification is received beyond the 15th, tuition will be processed automatically as normal and is NON-REFUNDABLE. Your withdrawal request will be processed for the following month.

Signature *

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