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Employee Application
CHILDREN'S SUCCESS SEMINAR
Membership Cancellation Request On-Line Form
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Indicates required field
Student Name
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First
Last
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Reason of Canceling
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Personal Reason
Member is relocating his residence beyond a 25 mile radius from the academy.
Member is cancelling for medical (non temporary) reasons
Personal (Non-Medical) Reason
4 to 9 Months remaining in the agreement. Cancellation $499
10 and up Months remaining in the agreements. Cancellation $999
Relocation 25+ miles away from the academy
Multi-Style System or Kickboxing. Cancellation $199.99
Black Belt Member. Cancellation $ 299.99
Upload Proof of new address
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Max file size: 20MB
I understand that I must provide a proof of my new permanent address. A new ID card with the new address is an example of proof of the change of address.
Cancelling for medical Reason
Upload Medical Certificate File Here:
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Max file size: 20MB
Medical certificate must certify the impossibility of the student to participate to the classes. Must be a long term impossibility otherwise the membership can be put simply on hold.
Multi-Style System or Kickboxing.
I have read the above Agreement, understand and agree with its terms. If the cancellation payment is not remitted, the agreement will be active and the collection company will continue to bill the account.
Today's Date
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Member Signature (or guardian under 18)
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Submit
