Form
MEMBERSHIP HOLD 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 put my membership on hold (indicate length of time below).
*
1 month
2 months
3 months
Your membership will resume and your account will be automatically drafted after this hold period ends.
*
I understand
If your hold request is less than 1 week prior to your draft date, you may be drafted 1 more time. (If you do not know your draft date, please call the membership director)
*
I understand
If you want to reinstate your membership at any point during the hold, you should contact the membership director at the Y.
*
I understand
If you choose to cancel your membership during your hold period, you must complete the online membership cancellation form.
*
I understand
If you have extenuating circumstances and need to extend your hold, please contact the membership director.
I understand
Signature
*
Date
*
-
Month
-
Day
Year
Date
I would like to make a charitable donation to the Y Partners Annual Campaign. The amount will be drafted from your account.
*
Enter 0 if you are unable at this time.
Submit
Should be Empty: