GHBPA Student Account Withdrawal Request Form

Student Name: _____________________________ Grade: ____

(Last, First, Middle Init.)

Event: _________________________________ Date: ________

(i.e. Spring Education Seminar, Summer Prep Course) (mm/dd/yy)

This form is for requesting the withdrawal of an individual’s Student Account funds and applying them towards the cost of an authorized event. It specifically directs and authorizes the Student Accounts Treasurer to transfer funds on behalf of the student for that purpose. This form must be completed and signed only by the parent/guardian of the student. Withdrawal Requests will be accepted anytime up until the published cutoff time for the specific authorized event. Parents who have also submitted Scholarship Applications for the same event will automatically have any awarded scholarship funds applied prior to utilizing their Student Account funds. Forms must be deposited into the Student Accounts Box (white metal box mounted on the wall in the band room).

· This form is the only method that will be accepted for withdrawal and application of individual Student Account funds.

· Submission cutoff dates are established and published for each authorized event. Please familiarize yourself with the established cutoff date for your specific authorized event. Withdrawal forms received after the published cutoff date will not be accepted!

· This form does not replace or serve as a substitution for the Scholarship Application form and is not related in any way to that program. Students/parents wishing to take advantage of that program must still submit the required forms in compliance with that program’s requirements.

Parent/Guardian: Please read the following acknowledgement, complete form and sign below:

As the legal parent or guardian of the above named student, I hereby acknowledge, understand, and give my consent, for the Student Accounts Treasurer to automatically withdraw and transfer all available and required funds from the above named individual’s Student Account, up to the maximum amount due, and apply those funds toward the individual costs of the specific authorized event. Additionally, if the required amount differs from the available balance in the student account, then only the lesser of those two amounts will be withdrawn and applied toward the event costs, with any remaining balance still due.

Parent/Guardian Information:

_______________________________________ __________

(Parent/Guardian Last Name, First Name) (Phone #)

______________________________________ __________

(Parent/Guardian Signature) (Date)

NOTE: Per IRS regulations, only that portion of Student Account funds that were individually deposited may be disbursed directly to the student for spending money. All other Student Account funds must be disbursed directly to GHBPA for individual student authorized event costs. For any additional information, please email the GHSB Student Accounts Treasurer at “ghsb_studentaccts@cox.net”.

Revision 12/04/2007