Submit a Form : Refund / Prorate Request Form

Refund / Prorate Request Form

Please note:

Request must be submitted seven (7) days prior to course begin date.
Please allow up to 30 days for refund to be processed.

Account Information

Last Name

First Name

Phone Number

Email Address

Street Address City and Zip Code

Participant Information

Participant Last Name

Participant First Name

Course Name

Course Activity Number

Fee

If Other state reason

If Prorate Total Course Sessions

If Prorate Total Sessions Attended

Customer Signature

Date of Customer Signature

Instructor must sign before refund or proration can be processed (if applicable). Once you submit this request, request will be submitted to instructor for sign-off.

*** Click SUBMIT at the bottom (scroll past "Staff Use Only")

- - - For Staff Use Only - - -

Instructor Signature

Date of Instructor Signature

Household Number

Payment Type ____ Cash ____ Check ____ Credit Card

Payment Amount

Payment Date

Refund Amount

Attach Payment Receipt to this request

Received By Name and Date

Department Review Name and Date

Manager Review

Approved By

GM Review

Credit Card Refund Disbursement Approval 1

Credit Card Refund Disbursement Approval 2

Credit Card Refund Disbursement Approval 3