New Mozart Private Lesson Withdrawal Form

We're sorry to see you go but do hope that you will continue with music again soon.

Student's Name

First Name

Last Name

Parent/Guardian's Name

Required for students under 18.

First Name

Last Name

Teacher's Name

Instrument

Email Address

Phone

(###)

###

####

Reason for Withdrawing

On a scale of 1 to 10 with 10 being the most positive, how would you rate your teacher?

Very negative > Barely Positive > Somewhat Positive> Mostly Positive> Very Positive

Any suggestions for your teacher or New Mozart?

What could we have done differently to keep you as a student?

This is my 30 days withdrawal notice as specified on the New Mozart Private Lesson Policies. I understand that the withdrawal notice must be given within the 1st 7 days of the month to end lessons at the end of this month and if I submit this form after the 7th, my enrollment and monthly tuition will stop at the end next month.

Print name of the legal guardian or adult student

First Name

Last Name

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