Children's Center Refund Request

Refund Request

Parent/Guardian Name*
First Last
Child's Name*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Cal Poly Email*
Form of Original Payment
- Cash/Check
- Debit/Credit
Total Refund Amount Requested
Reason for Request*
If for the Poly Trekker program, please include session (i.e. week 3).
Date*
MM slash DD slash YYYY
Signature*
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