Recreation Department, 7007 Moeser Lane, El Cerrito, CA 94530

SCHEDULE CHANGE, TRANSFER OR CANCELLATION

FORM
Participants Name: _________Matteo
Robbins___________________________________
Parent/Guardian Name: _____Shoshana Sklare_____ Phone #____510 846 4066__
Address: _5616 Santa Cruz St______Richmond____________94804___________
Street Address
City
Zip Code
Email (to receive
confirmation):___shoshana77@gmail.com___________________________
PROGRAM NAME: __Adventure Camp__________________

Schedule Change
Days & Times Requesting:
__________________________________________________
Days & Times Canceling:
___________________________________________________
Transfer
Currently Enrolled In:
______________________________________________________
Transfer Enrollment To:
____________________________________________________

X Program Cancelation: Adventure Camp

unhappy with services and security
REASON FOR CHANGE:
PREFERED EFFECTIVE DATE: ____8/5/13 (total
refund)___________________________
*Note the City of El Cerrito requires 2 weeks notice for schedule changes, transfers
and program cancelations. Applicable charges will apply for schedule changes,
transfers and cancelations.
I understand that filling out this form does not guarantee the approval of my
request. I understand that the City of El Cerrito requires 2-weeks notice for any
change/transfer or cancellation.
Signature: _______________Shoshana Sklare__________ Date: _8/6/13_______
OFFICE USE ONLY

Cancellation Fee $____________ Transfer Fee $______________ Change Fee

$______________
Staff
Signature:______________________________________Date:____________________
___
Comments: