Please enable JavaScript in your browser to complete this form.Enter student details who are withdrawing - Step 1 of 2STUDENT INFORMATIONStudent 1Student Name *FirstLastSex *MaleFemaleSession *1A: Reading Mon-Thu 4:00 to 6:30 PM2A: Reading Sat-Sun 1:00 to 4:00 PMHIFZ: Mon-Thu and Sat-SunAdd AnotherAdd Another StudentCheck this box if you want to add more students, otherwise just click on NEXT button.Student 2Student Name *FirstLastSex *MaleFemaleSession *1A: Reading Mon-Thu 4:00 to 6:30 PM2A: Reading Sat-Sun 1:00 to 4:00 PMHIFZ: Mon-Thu and Sat-SunAdd Another 2Add Another StudentCheck this box if you want to add more studentsStudent 3Student Name *FirstLastSex *MaleFemaleSession *1A: Reading Mon-Thu 4:00 to 6:30 PM2A: Reading Sat-Sun 1:00 to 4:00 PMHIFZ: Mon-Thu and Sat-SunAdd Another 3Add Another StudentCheck this box if you want to add more studentsStudent 4Student Name *FirstLastSex *MaleFemaleSession *1A: Reading Mon-Thu 4:00 to 6:30 PM2A: Reading Sat-Sun 1:00 to 4:00 PMHIFZ: Mon-Thu and Sat-SunAdd Another 4Add Another StudentCheck this box if you want to add more studentsStudent 5Student Name *FirstLastSex *MaleFemaleSession *1A: Reading Mon-Thu 4:00 to 6:30 PM2A: Reading Sat-Sun 1:00 to 4:00 PMHIFZ: Mon-Thu and Sat-SunNextFAMILY INFORMATIONParent / Guardian Name *Email *EmailConfirm EmailPrimary cell phone number *Alternate cell phone numberStreet Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReason for withdrawalMoving awayChild not making progressPrivate tutoringCan not affordTiming not suitableNot happy with teachersNot happy with administrationClass too crowededOtherSuggestion or commentsHow can we do better in future?Current Monthly Deduction Amount *If you are keeping some students in the program, we will adjust the deduction amount to charge only for the remaining students.New Monthly Deduction AmountThis will be applicable if you keep some students enrolled in the program.Additional monthly donation to support needy studentsThis will be sadaqa-jariyah for you.Re-registration Fee *Re-registration fee of $50 per student will apply if you re-register the student within 6 monthsCutoff date for withdrawal and auto-deduct *Withdrawal must be received by 20th of the month to stop the next month's payment Note: - Tuition Auto-Deduction happens on monthly basis, The Withdrawal Form must be received before 20th of the Month to stop payment for next month. Otherwise the deduction will stop from following month.PreviousWebsiteSubmit
