Withdrawal Request Form

Student Full Name

Parent/Guardian Full Name

Primary Email for Confirmation

Phone

Instrument

Teacher

Weekly Lesson Length

30 mins

45 mins

60 mins

Regular Lesson Day/Time

Location

In‑Person (222 Spring St. West Roxbury)

Online - Zoom

Are you submitting this request before or after the 15th (ET)?

Before the 15th (stop charges for next month)

On/After the 15th (stop charges the following month)

Requested Last Lesson Date

Reason for Withdrawal

Would you like to switch to a different teacher at Horus Academy?

Yes

No

Additional Notes

I understand autopay is charged on the 1st of each month and that a written withdrawal submitted by the 15th (ET) is required to stop charges for the upcoming month.

I understand missed lessons do not reduce tuition and that Lesson Credits cannot be applied to tuition or exchanged for cash; credits expire 12 months after issue.

I understand any outstanding balances must be paid in full.

I understand any school‑loaned materials must be returned by my last lesson date (if applicable).

By submitting this form, I confirm I am the student (18+) or the parent/guardian, and I agree to Horus Academy’s Terms & Conditions, Tuition & Payment Policy, Attendance & Make‑Up Policy, Privacy Policy, and Use of Media.

Signature

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