Discontinuation Request


STUDENT’S NAME: ______________________________________________

This form stops the tuition fees (for accounts in good standing) 14 days after the instructor signs the form.

Fill out or Circle the appropriate information regarding your current lesson: 

Time: ___________

Day: Mon Tu Wed Th Fr

Duration: 30min 45min 60min

Date of discontinuation: _____________

Reason: __________________________________________________________________________________________________________

I understand that I am giving a 14 day notice of cancellation from lessons from the date this form is submitted to the instructor. I understand that full payment is required for the 14 day termination period. I am current with my tuition/fee payments and understand that if I withdraw from lessons before any make-up lessons are completed, these lessons are forfeited. There are no refunds for missed lessons. There are no refunds for missed make-up lessons. 

I understand that if I choose to return to the studio, I will be paying the current lesson rate, not the rate I paid at the time of discontinuation. 

Parent’s Signature: _________________________________________________ 

Date: __________________

Instructor’s Signature: ________________________________________

Date: ________________

Thank you