Child Care Withdrawal Form

Child Care Withdrawal Form
Please complete the following form to request a withdrawal from child care services.
Child's Information
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Registration Number (if applicable)
Parent/Guardian Information
Parent/Guardian Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Withdrawal Details
Date of Withdrawal Request
MonthDayYear
Date
Last Date of Attendance
MonthDayYear
Date
Reason for Withdrawal
Please provide any additional comments or feedback about your experience with our childcare program. Your input is valuable to us and can help us improve our services for other families.
By signing below, I, the undersigned, confirm the withdrawal of my child from Child Care Center and acknowledge the following:
- I have provided the center with sufficient notice according to the terms and conditions of the enrollment agreement.
- I understand that any outstanding fees or balances must be settled before my child's official withdrawal.
- I release the center from any future claims or liabilities related to my child's attendance.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Child's Information