Withdrawal Request Form

Student Name:*

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.

If this student takes more than one instrument, please specify whether you want them to be withdrawn from one or both.
Do you plan on attending any more lessons this month? If you select, no, you will be taken off of 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? **
Please CLICK HERE to choose an action! **
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. **
Representative who you spoke with about withdrawing: **
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