Enrollment Ineligibility and Termination Notice Form
Complete this form to formally notify and document that an individual is no longer eligible for enrollment and that their enrollment is being terminated.
Person's Full Name
*
First Name
Last Name
Person's Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Program or Enrollment Type
*
Date of Notice
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective Date of Termination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Ineligibility or Termination
*
Please Select
Failure to meet eligibility criteria
Non-compliance with program requirements
Voluntary withdrawal
Attendance issues
Other
Additional Comments or Notes
Name of Person Issuing Notice
*
First Name
Last Name
Role or Position of Person Issuing Notice
*
Submit Notice
Should be Empty: