Eau Claire YMCA Membership Cancellation Notice

YMCA of the Chippewa Valley Membership Change Form
Current Information

Keeping your information up to date helps us stay connected so you don't miss a thing!
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Street Address*
City*
State*
Zip Code*
Phone Number*
E-mail Address*
Home Membership Branch
Membership Changes

Charges may apply

Upgrade/Downgrade Membership
Change my membership type
from
to
When would you like this change to start?

MonthDayYear
Changes must be applied by the 1st of the month to ensure accurate status and fee for that month.To upgrade immediately, you will be charged the prorated difference in membership cost. No refunds will be given for downgrades. Family memberships are limited to 2 adults of the same household and their dependent.
Please list everyone on the membership and include their date of birth:
Example: John Smith 12/02/2004
Questions, comments or additional information:

Add/Remove Household Members
Choose:
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Choose:
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Choose:
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Choose:
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Questions, comments or additional information:

Request for Membership Hold
Place my membership on hold - $10 monthly fee
Start Date

MonthDayYear
When your membership will become inactive
End Date

MonthDayYear
When your membership will re-activate
Please indicate the reason for your hold:
Example: vacation, work, medical restrictions, etc.
Medical? Upload a note from your doctor and we will waive the $10 monthly fee.

Browse Files
You can use a picture or a screenshot! Cancelof
Questions, comments or additional information:

Waivers
Acknowledgement
Membership Dues Agreement: Members understand that all changes affecting their monthly draft, (i.e. billing information, holds, downgrades, termination) require a written notice before the end of the month prior to their next draft date. Any error must be identified no later than 60 days from the posted bank statement date. The YMCA is not responsible for errors occurring later than 90 days from the date of the initial error. The YMCA draft is a continuous membership plan. Memberships will remain in effect until properly terminated with the YMCA. The YMCA may, at their discretion, adjust the monthly membership rate applicable to the category of membership. Members will receive at least a 30-day notice of the change before a debit occurs at the new rate. The primary membership holder is fully responsible for their membership and for all persons associated with their membership, including their knowledge of the aforementioned policies and liability waiver. Member is responsible for providing accurate contact information including updated address, phone number, email address, and billing information including expiration date and account information.

Membership status changes: Changes to your membership, including additions and deletions and change in membership type must be processed by Members Services in writing. Family memberships apply to households with a maximum of two adults residing at the same address and children residing at the same address who are up to the age of 24, if a full-time student, and up to the age of 19, if not a student.

Request for Membership Hold: Memberships can be placed on hold indefinitely with proof of medical reason. Otherwise memberships can be placed on hold for up to 5 months with a hold fee of $10 per month.
By checking the box below, I have read and understand the policy above.*

I agree.
Signature*
Eau Claire YMCA | 700 Graham Avenue, Eau Claire, WI 54701 | 715-836-8460
Should be Empty:

Current Information

Membership Changes

Acknowledgement