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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City
10. State
11. Zip*
13. E-Mail Address*
14. Phone Number*
16. Name of Program Participant*
    List the name(s) of the program participant requesting the refund.
18. Name of Program*
    List the name(s) of the program in which the participant was registered.
20. Program Dates
    List the dates or session number of the program(s) for which you are requesting a refund.
22. Reason for Refund*
    State the reason for your refund request.
24. A City of Malibu Community Services Department staff member will contact you within 3 business days to provide a status on your request. For additional information contact Brittany Saleaumua at 310-456-2489 ext. 349 or BSaleaumua@malibucity.org
26. Please note that refund requests are contingent on the Community Services Department Refund Policy.
28. Community Services Department Refund Policy
    Refund Policy

    For information on administrative fees, method of refund, and the application period to request a refund, please review the refund policy effective January 13, 2020.
30. Digital Signature*
31. Date*
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

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