Student Name:*FirstLastMonth In Which You Would Like Withdrawal to Take Effect *This would be the first month you wish to be off the schedule and payments to stop. Note that you may not list NEXT month if you are submitting this form after the 15th. Date:01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901yearStudent's Instrument *If this student takes more than one instrument, please specify whether you want them to be withdrawn from one or both. Instrument:*Select InstrumentPianoVoiceViolinViolaGuitarDrumsUkulele Do you plan on attending any more lessons this month? If you select, no, you will be taken off of the schedule. **Yes, please leave me on the scheduleNo, you can remove me from the schedule Reason for Withdrawing * Please be as specific as possible.* Can you please provide some feedback about your teacher? ** Do you have another family member who will still be enrolled at Expressions on your account? **Yes, someone else in the family will still be enrolledNo, none of our family will be enrolled Please CLICK HERE to choose an action! **Please contact me in 1 month to start lessons againPlease contact me in 2 months to start lessons againPlease contact me in3 months to start lessons againPlease contact me in 4 months to start lessons againPlease contact me in 5 months to start lessons againPlease contact me in 6 months to start lessons again I acknowledge that this withdrawal will not be accepted for next month if this form was submitted after the 15th of this month, per the policy. I understand that any unused lessons after this form has been submitted will not be refunded back to me. ** Yes, I acknowledge and understand this withdraw policy. Representative who you spoke with about withdrawing: **Ms. Nyshia Cook I'm not sure/Don't rememberSubmitReset