Withdrawal Form

Thank you for having your child with us in Dancercise Kids. We're sorry to see you go. Please complete the form below and we will process your account, and contact you if any follow-up is required. We appreciate your business!

*Child's First Name:

Please enter your child's first name

*Child's Last Name:

Please enter your child's last name as used when you registered.

Account Number:

Please type in your Dancercise Kids account number. You can find this on any of your statements, if you have one. If you do not have a statement (you pay your center) please be sure to fill out all of the remaining fields so we can be sure to withdraw the correct child.

*Date Of Withdrawal:

/ /	Please choose the date from which you wish your child to be withdrawn from class. Remember that we ask for two weeks' notice prior to withdrawal and your account will be processed accordingly.

*Parent's First name:

Please enter your first name, preferably the name used on the registration form; this helps us to check that we have the right account

*Parent's Last Name:

Please enter your last name, preferably the name used on the registration form; this helps us to check that we have the right account

*E-Mail Address:

Your e-mail address is required in order to send you a confirmation

*Your street address:

Required in order to locate your account if you cannot provide your account number

*City:

Required in order to locate your account if you cannot provide your account number

*State:

Required in order to locate your account if you cannot provide your account number

*Zipcode:

Required in order to locate your account if you cannot provide your account number

*Reason For
Withdrawal:

My child is leaving the child care center and going to Kindergarten

My child is leaving the child care center for other reasons

The center is no longer offering the Dancercise Kids program

We're watching our budget and needed to cut back on extra activities

My child did not enjoy the class

We're switching to another dance program (please tell us which program, below)

We chose to switch to different (non-dance) activities

We had a poor experience with Dancercise Kids

Other:


	Please take a few more moments to give us feedback on your experience with Dancercise Kids

*My child enjoyed Dancercise Kids:

Agree Strongly

Agree

Disagree

Disagree Strongly

*My child learned something positive from Dancercise Kids:

Agree Strongly

Agree

Disagree

Disagree Strongly

*I thought the program was good value for money:

Agree Strongly

Agree

Disagree

Disagree Strongly

*The program appears organized and professionally run:

Agree Strongly

Agree

Disagree

Disagree Strongly

*I would recommend Dancercise Kids to other parents:

Agree Strongly

Agree

Disagree

Disagree Strongly

Please enter any
comments on the
program, instructors
or organization:

(chars left: 1000)

*Would you like to
receive an ecoupon
worth 25% off
downloadable music
at our online store?:

Yes please send me the ecoupon
No thanks

You must specify a valid e-mail address in order to receive your e-coupon

*Contact Phone Number:

- - x

In case we have questions about the information you provide in this form