Name of requestor _________________________________
Requesting repayment of funds for:
____ Tournament Fee (please see the tournament fee payment policy for specifics on what to include with request)
____ Coaching/Referee Clinic Fees (please provide all applicable receipts and verification of completion of the course with this form)
____ Player Refund ($25 withhold unless otherwise approved by BOD)
Reason for Request_______________________________________
_______________________________________________________
____ Other
Reason for Request_______________________________________
_______________________________________________________
_____________________________
(Requestor signature)
__________________
(Date)
For MYSA BOD Use Only
__________________ Request Review Date
____ Approved ____ Denied
Reviewed By ___________________________
For Player Refunds Only:
$25 Withhold Waived ____ Yes ____ No