Private/Semi-Private Withdrawal Form
One form per student per class
*Form must be submitted before close of business on the last working day of the month, including holiday closures, as your end date may affect your monthly billing.
Day of class:
Time of class:
Date of last class (must be at least 7 days from today's date)
I understand that I am forfeiting my space in this class by sigining this form.
I understand that if I have failed to submit this form at least 7 days before the 1st of the subsequent calendar month, I will be chagred the full monthly tuition and will not receive a refund for this charge.
I understand that once my withdrawal has been submitted I am no longer able to change my class time or day.
I understand by checking this box will serve as my electronic signature to the above agreement.
I have read & agree to the Withdrawal Policy.
I would like to pay the $30 Early Withdrawal Fee and withdraw as of today, instead of the 7 day (1 class advance) notice. (This fee can alternatively be deducted from any credit you have remaining from unattended prepaid classes for the month if applicable.)
Yes, please charge my credit card listed below the $30 Early Withdrawal Fee
Name on Card
Credit Card Type
Credit Card Number
Expiration Date (mm/yy)
(Authorizing ASA to charge my card)
Reason for Withdrawal or General Comments:
(Authorizing Atlanta Swim Academy to WITHDRAW FROM the class indicated above)