Participation / Cancellation Form printable pdf download

PARTICIPATION / CANCELLATION FORM

~Program Name~

~Due Date: ~

By signing this form, I understand and agree to the following:

_____ I hereby submit a deposit of $500 to confirm that I will participate in this program and I

understand that this deposit is non-refundable..

_____ I understand that this deposit will be credited to my student account toward the total cost

of the program.

It is important to note that you are only asked to pay the $500 non-refundable deposit at this

time. However, if for any reason you withdraw before or during the course of the program, the

amount shown on the following schedule represents the cost of the program to the date of

withdrawal and how much Purdue is charged by the overseas housing agents, service providers,

and suppliers. The amount Purdue is charged must therefore be passed on to the student.



Withdraw before March 11, 2013……………………………………. $500 deposit forfeited



Withdraw March 11 – March 18, 2013……………………………. $1500 of program fee + the deposit



Withdraw March 19-March 31, 2013………………………………. $2500 of program fee + the deposit



Withdraw after April 1, 2013…………………………………………… student is responsible for all fees

related to program.

In addition, if you withdraw after the start of the program or are removed from the program, no

refund will be given. Additional penalties for cancellation of airline tickets and other personal

expenses may apply

_____ I fully understand the above cancellation policy.

_____ I fully understand that notice of withdrawal must be made in writing to ~Program Leader~

The date the email, fax or letter is received is the date by which any refund will be calculated.

_____ I further understand that if I am placed on disciplinary probation for any reason, at any

time prior to the program start date, my approval to participate will be revoked and I will be

liable for any fees associated with this cancellation policy.

My name is _________________________________________ (please print) and by initialing

the paragraphs above and signing this form, I confirm that I understand the stipulations

and agree to the policies and penalties herein.

____________________________

Student signature

Date of signature

* Note to students receiving financial aid (including student loans and scholarships): if you

withdraw after receiving financial aid, you do not get to keep the money you received. The

Bursar Office will invoice you for the financial aid that you received, and in addition, you will be

billed the above cancellation fees.

Participation / Cancellation Form