COURSE WITHDRAWAL FORM

Student Details
Student Name*
First Last
Email Address*
Phone Number
Course Details
Please note: You will need to fill out this form for each course that you would like to extend.
Course Name*
Course Teacher*
Course Activation Date*
Date Format: DD slash MM slash YYYY
Reason for Extension*
Please specify the reason you were unable to complete this course:
- Health
- Too Busy
- Unforeseen Circumstances
- Not Motivated
- Other
Plan for Completion of the Course
Course Completion Plan
Please outline your weekly plan for the next 3 months that will enable you to complete the course.
Agreement
Agreement*
I understand that I have to pay a non-refundable tuition of $150 for this extension, and when this form is completed successfully, I will have an additional 3 months added to the course term. I understand that if I do not complete this course in the allotted term, I will be withdrawn from this course. Once Withdrawn I will no longer be able to complete this course and will have to be re-enrolled and start the course from the beginning.
- Yes, I agree to the terms listed above
- No, I do not agree to the terms listed above
Signature*

Please type your full legal name to the above statement. Typed names suffice as handwritten signatures.
Extension Approval (Office Use)
- Principal
Signature and Date
- To Accounting
Signature and Date
- To Records
Signature and Date
- Payment Received
Signature and Date

Student Details