Student name *

First Name

Last Name

Reason for cancellation? *

Check all that apply (if choosing "OTHER" please tell us more in the field below)

Schedule conflict

Financial conflict

Not satisfied with quality of program

Motivation / Goal setting issue

Moving out of area

Reached my goal and wish to pursue other activities

Other

Did you consider our "Reservation Rate" option which allows you to keep your discounted rate and roster space secure during your break? *

No

Yes

Were you able to address all concerns with the studio manager? *

No

Yes

What is your proposed return date? *

Less than 2 months

2 - 4 months

4 - 8 months

Not sure

I am not planning on returning

If you would like to refer someone to take over your program allowing you to avoid any cancellation fees while introducing someone new to the life-changing benefits of martial arts, please complete the below information. If they enroll within the next 30 days then your membership will be closed out with no further obligation. Thank you!

First Name

Last Name

Your referral's phone number

(###)

###

####

Referral legal guardian's name

(if under age 18)

First Name

Last Name

By checking here you agree to the terms outlined below: *

This form shall serve as my official 30-day advanced written notification required to cancel my student membership agreement. I understand that my program will be cancelled only when my outstanding balance has been paid in full, which may include but isn’t limited to, past due tuition, cancellation fees, tuition discounts, enrollment discounts, apparel purchases, and special event attendance. Early termination fees are calculated based on the month-to-month membership retail rate plus reimbursement of the monthly discount received for each month completed in my program. I also understand that after cancelling my program I may not be eligible to re-enroll with the same terms and conditions due to promotional rates ending, price increases, class schedule changes, classes at full capacity, or other and that I may be subject to a re-enrollment fee upon my return. I agree to settle my account to a $0 (zero dollar) balance immediately upon submitting this form if applicable. Upon completing this notification, I realize my credit card on file will be charged automatically the full amount owed. If my card is declined upon the first attempt to reconcile my account there will be additional attempts to reconcile my balance by charging my card at least 50% (fifty-percent) of the balance owed, followed by the remaining 50% (fifty-percent) within 7 (seven) days with no prior schedule or notification required. I further understand that I will be liable for late fees and/or other related procedural expenses such as legal and/or third-party collections should I default on this agreement. If there are special circumstances or concerns that affect this agreement I agree to address them with the studio manager immediately. By entering my name below I swear that I am the responsible party of the membership agreement being requested for cancellation and accept full responsibility of this agreement.

Responsible party name

First Name

Last Name