WALTON CHORUS

INDIVIDUAL STUDENT ACCOUNT

WITHDRAWAL FORM

I, _______________________________________________________________ request that

___________________________________________________ dollars and __________ cents

($_________________) be withdrawn from my student account for the following purpose:

 ___________________________________________________________________.

______________                                                _______________________________________      Date                                                                     Student or Parent Signature

Chorus: _______________________________________________________

All withdrawals are subject to final approval by the Board of Directors

For use by Booster Treasurer:

Withdrawal approved and recorded_____________________________________________