Withdrawal, Refund and Insurance Opt-out Request Form

General Information

I am a student of:(Required)

York University Professional Programs

the York University English Language Institute (ELI)

Hidden

Date

As per our policies, the date that you submit this request impacts your refund eligibility. Please review the relevant policy here: https://continue.yorku.ca/support/policies/ before submitting a withdrawal request.

Name(Required)

First Last

Student Number(Required)

Email(Required)

Enter Email Confirm Email

Type of Request

I would like to request a(Required)

withdrawal from a program or course

refund for overpayment

opt out and/or refund for insurance

refund for residence/meal plan or other optional fees

Overpayment Refund Request

Please fill in the refund request details below. Please confirm that your student portal is showing an overpayment before submitting a request.

Residence/Meal Plan or Optional Fees Refund

I am requesting a refund for(Required)

Residence Fees

Meal Plan Fees

Other

Other Refund Request Details(Required)

Please provide details on what you are requesting a refund for.

Opt Out and/or Refund Request for Insurance

Please note: All students are required to have health insurance that covers the length of their course.

Type of Insurance Request(Required)

Check all that apply.

I would like to opt out of insurance

I would like to request a refund for insurance (only if already paid)

Opt Out of Insurance

Please note: The deadline to opt out of insurance is the end of week one (1) of your program. If you do not cancel your insurance with us by that deadline, insurance will be ordered for you, and you will be required to pay the fee. If you have your own personal insurance that will last the length of your program, you may request to cancel insurance with us.

Proof of Insurance(Required)

Please upload proof that you already have insurance. Proof of insurance must clearly indicate the student’s name, the policy number, the start and end date of the policy and must be valid for the entire length of the program.

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Request a Refund for Insurance

Please confirm that you have already paid for insurance before requesting a refund by reviewing your payments in the Student Portal. See below for instructions.

Withdrawal

Are you withdrawing from more than 1 program?(Required)

For example, 1 English Language Institute program and 1 Professional Program.

Yes

Important Note: You will need to submit a separate withdrawal form for each program that you wish to withdraw from. At the end of this form, you will be sent back to submit another withdrawal form.

When is the start of your program?(Required)

Would you like to withdraw from a program or a course?(Required)

Entire program

One or more courses (not applicable to ELI)

Program Withdrawal Information

Program Name (Professional Education)(Required)

Program Name (English Language Institute)(Required)

Have you previously deferred ?(Required)

As per Policy, students who have previously deferred may not be eligible for a refund. Please review the relevant policy here: https://continue.yorku.ca/support/policies/.

Yes

Reason for Program Withdrawal(Required)

Visa Denial

Other

Other Reason for Program Withdrawal(Required)

Enter a short description for your withdrawal reason. You can provide longer comments below.

Upload Visa Denial Letter(Required)

Please upload a copy of the Visa Denial letter and any other supporting documents.

Drop files here or

Max. file size: 8 MB, Max. files: 8.

Upload Supporting Documents

Please upload a copy of any supporting documents.

Drop files here or

Max. file size: 8 MB, Max. files: 8.

Course Withdrawal Information

Course List(Required)

Please list all of the courses you wish to withdraw from. Please include the full course code (e.g. CSBA1020).

Reason for Course Withdrawal(Required)

Course Exemption

Other

Upload Supporting Documents

Please upload a copy of any supporting documents.

Drop files here or

Max. file size: 8 MB, Max. files: 8.

Other Comments and Refund Request

Other Comments

Please provide additional details to explain your request.

Would you like to apply for a refund?(Required)

Please review policy to see refund eligibility criteria: Please review the relevant policy here: https://continue.yorku.ca/support/policies/.

Yes

Payment Information

Please review your payments and check your balance before filling in the refund request details below. Follow the steps below to do so.

Log in to the Student Portal here: https://my.continue.yorku.ca/portal/logon.do?method=load
On the left sidebar, click on “My Account History”. Review all transactions/payments.
On the left sidebar, click on “My Invoices”. Review any outstanding invoices (money that is still owing).

My Invoices Example:

My Account History Example:

Would you like your refund allocated to your York University student account?(Required)

This is NOT your School of Continuing Studies student account. Only choose this option if you are also a degree-program student with York University.

Yes, please allocate my refund to my York University account.

No, please refund my original payment method.

Approval-York University Account Refund(Required)

I approve this refund going to my main York University account and I understand that I will no longer be eligible for a refund to my original payment method. I understand this this is NOT my School of Continuing Studies account.

How did you pay your tuition? (Select all that apply)(Required)

Check all that apply if you paid via multiple payment methods. Please note: refunds are sent only through the original method of payment and/or to the original payee.

Credit Card

Convera Global Pay

Bank Wire & Bank Transfer or Certified Cheque/Money Order/Bank Draft

Debit/Interac (In-Person)

Other

Other Payment Details(Required)

Please provide details on how you paid your tuition.

Please note, if you are eligible for a refund:

All payments made through Convera Global pay will be returned to the source account whenever possible. Payments made through Convera Global Pay which cannot be returned to the original payee will be refunded by wire transfer and may require approximately 7-8 weeks for processing.

Credit Card refunds may require 1-2 weeks for processing.

Bank Wire refunds may require 7-8 weeks for processing. The account holder name, bank name and bank account number entered into this form must match EXACTLY with the proof of payment that you upload.

Bank Wire & Bank Transfer Information

Did you send your payment from multiple different bank accounts? (Different account numbers, different account holder name, etc.)(Required)

I paid my tuition from only one bank account, under the same account holder

I paid my tuition from two different bank accounts

I paid my tuition from three different bank accounts

Bank Wire Information #1

Please enter the details of the first bank account that you paid from. This must match our records of your payment.

Account Holder #1: Name(Required)

First Last

Account Holder #1: Email(Required)

Account Holder #1: Phone Number(Required)

Account Holder #1: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank #1: Name(Required)

Please enter the name of your banking institution.

Bank #1: Phone Number(Required)

Bank #1: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The following image is an example of how to find the Transit, Institution and Account numbers from one of your cheques.

Bank #1: Transit Number(Required)

This must match the transit number for the
Canadian bank account that you paid from.

Bank #1: Institution Number(Required)

This must match the institution number for the
Canadian bank account that you paid from.

Bank #1: Account Number(Required)

This must match the account number that you paid from.

Bank #1: VOID Cheque/Direct Deposit/Pre-Authorized Debit Form(Required)

Please upload a VOID cheque, Direct Deposit Form or Pre-Authorized Debit Form matching the transit, institution and account numbers for your Canadian bank account. The details must exactly match the account that you paid from.

Most major banks make this form available through their online banking sites. Please contact your bank for details.

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank #1: SWIFT Code(Required)

Bank #1: Proof of Payment(Required)

Upload proof of payment. Documents need to clearly identify the payor name and the amount paid.

The account holder name, bank name and bank account number entered into this form must match EXACTLY with the proof of payment that you upload.

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank Wire Information #2

Please enter the details of the second bank account that you paid from. This must match our records of your payment.

Account Holder #2: Name(Required)

First Last

Account Holder #2: Email(Required)

Account Holder #2: Phone Number(Required)

Account Holder #2: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank #2: Name(Required)

Please enter the name of your banking institution.

Bank #2: Phone Number(Required)

Bank #2: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The following image is an example of how to find the Transit, Institution and Account numbers from one of your cheques.

Bank #2: Transit Number(Required)

This must match the transit number for the
Canadian bank account that you paid from.

Bank #2: Institution Number(Required)

This must match the institution number for the
Canadian bank account that you paid from.

Bank #2: Account Number(Required)

This must match the account number that you paid from.

Bank #2: SWIFT Code(Required)

Bank #2: VOID Cheque/Direct Deposit/Pre-Authorized Debit Form(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank #2: Proof of Payment(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank Wire Information #3

Please enter the details of the third bank account that you paid from. This must match our records of your payment.

Account Holder #3: Name(Required)

First Last

Account Holder #3: Email(Required)

Account Holder #3: Phone Number(Required)

Account Holder #3: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank #3: Name(Required)

Please enter the name of your banking institution.

Bank #3: Phone Number(Required)

Bank #3: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The following image is an example of how to find the Transit, Institution and Account numbers from one of your cheques.

Bank #3: Transit Number(Required)

This must match the transit number for the
Canadian bank account that you paid from.

Bank #3: Institution Number(Required)

This must match the institution number for the
Canadian bank account that you paid from.

Bank #3: Account Number(Required)

This must match the account number that you paid from.

Bank #3: SWIFT Code(Required)

Bank #3: VOID Cheque/Direct Deposit/Pre-Authorized Debit Form(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank #3: Proof of Payment(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 4.

Bank Wire & Bank Transfer Authorization

Bank Wire & Bank Transfer Authorization(Required)

I/we, the above named business/individual, authorize York University to credit my/our bank account(s) indicated above. I/we will notify York University Accounts Payable promptly in writing if I/we move the account(s) from one financial institution or branch to another or if there is any change in the account(s). I/we are authorizing signing officer(s) for the business or account(s). I/we have retained a completed copy of this authorization form.

Declaration and Final Comments

Comments

Please enter any other comments you have on your request here.

Declaration – Withdrawal(Required)

I confirm that I have read the refund policy and agree with its terms. I understand that submitting this form does not guarantee my eligibility for a refund.

Declaration – Overpayment(Required)

I confirm that I have checked my student account and that it shows an overpayment.

Declaration – General(Required)

I confirm that I have read the school policies and agree with their terms. I understand that submitting this form does not guarantee my eligibility for a refund, if requested.