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                               1200 LIBRARY DRIVEBENTON, AR 72015



                      Checking, Credit Card or Debit Card Auto Pay
                                   CANCELLATION REQUEST

CANCELLATION TERMS REMINDER – Leah’s Gymnastics & Cheerleading, Inc. will charge the listed
banking account or credit card and extend the child’s enrollment exactly one month until this
authorization is cancelled in person and in writing below. Retroactive cancellation is not possible under
this agreement. The undersigned agrees to inform Leah’s Gymnastics & Cheerleading, Inc. of any change
in checking account information, credit card number, and issuer or expiration date. Should the card be
rejected for any reason, this agreement will immediately lapse and the enrollment will be discontinued
until payment is made. The signer below assumes liability for this agreement, as stated herein. Thirty
(30) days written notice is required for cancellation and make-up classes must be taken within this 30
day period. There will be a $30 service charge for all declined charges.

The signer hereby wishes to cancel his/her Leah’s Gymnastics & Cheerleading, Inc. Monthly Payment
Agreement, as of the date noted below. It is agreed that no further charges will be made against the
above listed account. Charges processed prior to this notification are deemed paid and earned.

                   No refunds or credits will be available for classes not attended.

Please cancel Auto Pay & do not charge my checking account or credit card effective the

1st of _________________, 20_____

Cancellation request date________________________ (30 days Pryor to cancellation)

___________________________________________                     ____________________

Customer Signature                                              Date

Student’s Name_______________________________

___________________________________________                     ____________________

Leah’s Gymnastics & Cheerleading Signature                      Date