AlliedRx · Withdrawal / Leave of Absence Request

Who you are

Use the name and email on your enrollment agreement so we can match your record.

Full legal name *

Enter your full legal name.

Email address *

The address you enrollled with.

Enter a valid email address.

Date of birth *

Enter your date of birth.

Last 4 of Social Security number *

Used only to verify your identity.

Enter exactly 4 digits.

Phone number

In case we need to reach you.

Your program

These determine which refund schedule applies to you.

Program *

Select your program.

How you attend *

Select how you attend.

How your program is funded *

We check this against your payment record, so do not worry if you are unsure — we will use whichever your account shows.

Select how your program is funded.

Program start date

Taken from your enrollment record.

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What you are requesting

A leave of absence is different from a withdrawal. Choose carefully.

WithdrawalI am leaving the program and do not intend to return. Leave of absenceI need time away and I intend to come back. Supporting documentation required. Military leave of absenceLeave for military service. Military orders required.

Choose one.

Your last date of attendance

Why are you leaving? *

This helps us understand whether there is something we can do.

Please tell us why you are leaving.

Tell us what is happening *

Please tell us why you are leaving. It helps us support you, and in some cases it changes what we are able to offer.

Please tell us what is happening.

Please give us a little more detail — at least a sentence.

Before you go — there may be another option

You told us the payments have become unaffordable. If that is the only reason you are leaving, we would rather change the payments than lose you.

Your balance does not change These options spread what you already owe over a longer period, or pause it for a while. You are not charged extra, and nothing is added for choosing one.

Not ready to leave, but not able to pay right now? — pause your studies and come back, keeping your place.

Choose an option to continue.

Prefer to withdraw anyway? That is completely fine. Choose “No thank you, continue with my withdrawal” above and we will process your request as normal.

Verify and sign

Required before we can process your request.

Photo ID *

Driver's license, state ID or government-issued ID.

Click to upload — PDF, JPG or PNG

A photo ID is required.

I attest under penalty of perjury in the Commonwealth of Virginia that I am the named student making this request and that everything I have entered above is true and correct.

You must confirm this to continue.

I understand that my last date of attendance is the date I submit this withdrawal form. I understand this date is used to determine the portion of my program that was delivered, and therefore the refund I am entitled to.

You must confirm this to continue.

I have read and understand the cancellation and refund policy in my enrollment agreement, including that the registration fee is non-refundable, that a $100 cancellation fee is retained in addition to it, and that no refund is due once 75% or more of the program has been delivered.

You must confirm this to continue.

I understand that disputing or charging back tuition or fees while this withdrawal is being processed, rather than following the withdrawal procedure, is a breach of my enrollment agreement. My agreement states that “chargebacks without going through the withdrawal process may result in collections, credit bureau reporting, and/or attorney costs and fees.” I understand that a chargeback made in bad faith may be referred to legal counsel, and that under the Contract Acceptance terms of my enrollment agreement AlliedRx “may declare the entire unpaid balance immediately due and payable without further notice,” that I agree to pay interest at 1.5% per month (18% per annum) or the maximum rate permitted by Virginia law, whichever is less, and that I agree to pay all costs of collection “including attorney’s fees equal to twenty-five percent (25%) of the unpaid balance, together with all court costs, filing fees, service fees, sheriff’s fees.” I understand this agreement is governed by the laws of the Commonwealth of Virginia and that I have consented to jurisdiction there, and that any action may be brought in the General District Court or Circuit Court for Chesterfield County, Virginia.

You must confirm this to continue.

Type your full name to sign *

Your signature must match the name you entered.

Date

Check your answers

Once submitted this becomes your formal written notice.

What happens next A member of staff reviews your request and calculates any refund due under your enrollment agreement. If you are on a payment plan it is canceled straight away so no further payments are taken. Refunds are issued within 45 days and returned to your original payment method.

Request a withdrawal or leave of absence

Request canceled

You're staying with us

Your new payment plan

Request received

Already submitted a request?