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2. Today's Date:*
   Today's Date:
4. Contact Information
6. Parent/Payee Name:*
7. Email Address:*
9. Address:*
11. City:*
12. State:*
13. Zip Code:*
15. Day Phone:*
16. Evening Phone:
18. Participant's Name:*
19. Participant's Date of Birth:*
23. Class or Rental Details
25. Were you enrolled in a class or renting a facility?*
    -- Select One --Enrolled in a class.Renting a facility.
27. If enrolled in a class, please write name of class:
28. Instructor:
30. If renting a facility, please write name of facility:
32. Is this a request to refund or transfer your fee?*

    1. Refund
    2. Transfer
34. Reason for the Refund/Transfer:*
    For transfer requests, please provide as much information as possible about the preferred future program.
36. The reason for this refund/transfer is due to the COVID-19 response.

    1. Yes
38. Comments:
40. Signature:*
Leave This Blank:


42. Submit Submit and Print

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