Membership Hold/Cancellation Form

1

Please enter your information:* This field is required.

First Name

Last Name

Phone Number

Email Address

2

Date of Birth

Date of Birth (MM/DD/YYYY)

3

Home YMCA Facility* This field is required.

4

Would you like to hold your membership?* This field is required.

YESNO

5

Would you like to cancel your membership?

YESNO

6

Why are you holding your account?* This field is required.

7

Would you like to donate your membership dues while on hold?

YESNO

8

Please select the amount of your donation

Donate my full membership dues

Donate $50 per month

Donate $100 per month

Donate $150 per month

9

Who should we cancel?

10

Who should we remove?

11

Reason for cancellation* This field is required.

12

How many months would you like to place your membership on hold?* This field is required.

13

Any additional information we should know?

14

Any additional information we should know?

15

PLACING YOUR MEMBERSHIP ON HOLD

Memberships may be held for up to six months in a calendar year. I understand changes to my membership account must be received by the 25th day of the month in order to ensure no charges will take place in the following month. Holds take effect on the first of the month and end on the last day of the month. Membership holds must be for all active people on a membership unit. Members may take their account off hold at any time during the hold period. They then pay the prorated amount for the rest of the month and begin drafting as normal the following month.

16

I understand my normal membership dues will automatically restart after my hold period has ended. Signature* This field is required.

Clear

17

I understand changes to my membership account must be received by the 25th day of the month in order to ensure no charges will take place in the following month. If a membership lapses for more than 30 days, a rejoining fee will apply. Signature* This field is required.

Clear

18