Student Account Withdrawal Form

STUDENT ACCOUNT WITHDRAWAL FORM

Please mail to Melissa Kennedy @ 5326 E.Kathleen Rd Scottsdale, AZ 85254

Horizon Band Parent Association Treasurer:

I ________________________________ would like you to take $_____________ out of my

(Print Name clearly)

account for _________________________________________________________________

(State use)

Thank you, __________________________Date ________

(Your signature)

My Student Account Number is: _____________

Deliver check to: ______________________________________________________________
___________________________________________________________________________
(Please state how you would like the treasuer to get you the check. Provide address if you want it mailed). Please print neatly.

This may be authorized by student or parent.

DIRECTOR APPROVAL AND A RECEIPT ARE REQUIRED FOR ALL REQUESTS
EXCEPT: Band Camp, Band Banquet, Shoes & Gloves, and California Trip.

Approval Signature: ___________________________________________________________

Band Director

Date

Horizon Pride Regiment