Refund Request Form for Purchases

Customer's First and Last Name

Customer's Child's Name (If applicable)

Mailing Address

City, State, Zip

Phone Number

Email Address

Date of Original Transaction

Amount of Original Transaction

Description of Item(s) to be Refunded

What Program/Class/Membership do you want a Refund for?

Payment Transaction Order Number - Found on Receipt

Payment Method

Cash

Check

Credit Card

UBill

Credit Card Type Used for Transaction (If Applicable)

Visa

Mastercard

Discover

Last 4 Digits of Credit Card Used (If Applicable)

Invoice Number (If Applicable)

Full or Partial Refund

Full

Partial

Reason for Refund

Submitted By