- Palatine Park District

Application for Transfer/Withdrawal

"*" indicates required fields

Name*

First Last

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Email Address*

Request Type*

Program Code #*

New Program Code #

Program Name*

Please Indicate Reason for Transfer or Withdrawal*

Conflict

Medical (Doctor’s Note Required)

Dissatisfaction

Other

Please Elaborate*

Type of Refund Requested*

Refund To Original Form of Payment ($5.00 Processing Fee)

Household Credit

Upload Medical Note

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Max. file size: 100 MB, Max. files: 5.