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Iowa Rush South - Refund Request Form
This request form must be completed in its entirety before it will be reviewed by Iowa Rush South board members to determine if a refund or partial refund is approved or possible based on what the registration was for, the refund policy stated during that registration, the timing of the refund request to when the soccer program begins, and any circumstances beyond control such as injury or moving from the Pella location.
Player's Name
First
Last
Enter the name of the player who was registered for an Iowa Rush South program.
Players Birth Date
*
MM
/
DD
/
YYYY
Enter date of birth of player - example 05/03/2010.
Parent/Guardian Name
*
First
Last
The person submitting this form must be a parent or guardian of the player who was registered.
Soccer Program Registered For
*
Fall Kickoff Camp
Fall Soccer Season
Winter Academy
Spring Soccer Season
Select the soccer program that this player is registered for that you are requesting a refund for.
Parent / Guardian Email Address
*
Reasons for Refund Request
*
Please be sure to include any additional information needed to make the form official such as a detailed Medical Note stating diagnosis of injury or extended illness, etc.. A form can be uploaded with this form separately.
Upload Medical Note if for medical reasons
Upload a medical note from a doctor if stating diagnosis of injury or extended illness, etc..
====== PLEASE SCROLL DOWN AND SELECT THE SUBMIT BUTTON =======
The BELOW section is for Iowa Rush South use only - DO NOT ENTER information BELOW THIS SECTION.
Registrar/Admin - Check all that apply
Adequate Support Documentation Receivedd
Support Document NEEDED
Refund Approved
Refund Denied
Registrar/Admin NOTES
Payment Information === FOR CLUB ADMINISTRATION ONLY ===
To be entered by Iowa Rush South Registrar/Admin for tracking purposes.
Initial Payment
$
Dollars
.
Cents
Do not include Payment Plan not paid.
LESS Administrative Fee ($20) plus any other fees Iowa Rush South has already paid out to City of Pella, Iowa Rush, or Iowa Soccer.
$
Dollars
.
Cents
Total Reimbursement (if approved)
$
Dollars
.
Cents
If a reimbursement is approved, it will be less the Administriative Fee and any other fees that the Iowa Rush South has already paid out to the City of Pella, Iowa Rush, or Iowa Soccer, etc..
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