After-School Program Withdrawal Form

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Please fill out and submit the After-School Program Withdrawal Request form. The date of the submitted form is the official date of notification in accordance with the Withdrawal Policy outlined in the Kirov Academy After-School Program Handbook.

After-School Program Department
In order to complete the withdrawal request form as an enrolled student in the Kirov Academy After-School Program (ASP), please indicate the appropriate After-School Program Department you are enrolled in.
Which ASP Department(s) are you withdrawing from?*
Please select the ASP Department(s) the student is withdrawing from. If the student is taking a class in multiple ASP Departments please select all that apply to this withdrawal request.
Contact Info
Student Name*
First Middle Last
Parent Name/Legal Guardian*
Prefix First Last
Email of Parent/Legal Guardian*
Based on the selection of the ASP Department, the appropriate Program Head will contact the Primary Parent / Legal Guardian to confirm the withdrawal request.
Enter Email Confirm Email
Phone of Parent/Legal Guardian*
Withdrawal Request Information
In this section please provide the reason for withdrawal. Please refer to the Kirov Academy After-School Program Handbook for the full withdrawal policy.
Notification Date of Withdrawal*
YYYY dash MM dash DD

Please enter today's date that you are notifying Kirov Academy of your withdrawal request.
Reason for Withdrawal*
Please describe your reason for withdrawal. To comply with Kirov Academy's withdrawal policy, please refer to the After-School Handbook you received upon enrollment. If you require another copy, please contact your ASP Program Head.
Please indicate if this is a medical withdrawal?*
- YES
- NO
If the reason for withdrawal is medical, please check "YES" and you will be prompted to upload a copy of the documentation for a medical withdrawal.
Withdrawal Documentation
Max. file size: 512 MB.
A copy of the documentation for medical withdrawal is needed in accordance with Kirov Academy's After-School Program Withdrawal Policy. Please upload a copy of the medical withdrawal officially issued from the presiding doctor, nurse, emergency staff and/or clinic.
Signature
I , the undersigned, agree to the Kirov Academy After-School Program's Withdrawal Policy and that I am giving 30 days notice of withdrawal of the student mentioned above. I will continue to be responsible for outstanding payments due for the period of 30 days from this dated document.
Consent*
I agree to the withdrawal policy laid forth in the Kirov Academy After-School Handbook.
Signature of Parent/Legal Guardian*
First Last
As the designated Primary Parent/Legal Guardian, please type your Legal Full Name to act as your Wet Legal Signature.
Date of Signature*
YYYY dash MM dash DD

After-School Program Withdrawal Form

After-School Program Department

Contact Info

Withdrawal Request Information

Signature