Cancellation Request Form
If you want or need to withdraw from classes, please fill out and submit this form.

Month-to-month plan can be cancelled at any time. However, all cancellation requires a minimum of 30 days written notice prior to next billing date to assure cancellation of automatic payments.




USA Shaolin Xiu Culture Centre
21732 Provincial Blvd. #100
Katy, TX 77450
832-363-7994

Email *
Phone Number: *
Student Last Name: *
Student First Name: *
In order to cancel classes, USA Shaolin Xiu Culture Centre must be notified at least 30 days before your next billing date. *
Required
If you cancel classes, all make-ups must be used before the date of your last class. Any unused make-ups will be lost after the date of your last class. *
Required
The last date of student's attendance *
MM
/
DD
/
YYYY
I am dropping out of class(es) because: * *
Student or Parent/Guardian Full Name *
Please type the full name of student or parent/guardian filling out this form. Student MUST be 18 years of age or older.
Questions / Comments
Today's Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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