Form
MEMBERSHIP CANCELLATION FORM
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I would like to CANCEL my membership. I understand the 30-day cancellation policy that I signed when enrolling for the YMCA. I understand that the 30 days starts on the day that the YMCA receives this form, and that my account will be draft one more time before canceling. I understand to re-enroll to the YMCA I might be required to pay enrollment due, have a new membership rate, and fill out all new paperwork.
*
Cancel my membership (this is my 30 day notice)
Please select the reason you are cancelling your membership:
*
Non-Use
Moving
Medical
Financial
Insurance Requirement
Cleanliness
Program Quality
Other
Could the Y have done anything differently to improve your experience?
Overall, how satisfied were you with your membership?
*
1
2
3
4
5
1=not satisfied at all / 5=exceeded expectations
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: