Request for Membership FREEZE FORM

BECKER COMMUNITY CENTER

REQUEST FOR MEMBERSHIP FREEZE FORM
MEMBER NAME *

First Name Last Name
MEMBERSHIP #
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Email
example@example.com
FREEZE POLICIES:
- 30 day written notice is required.
- Membership must be in good financial status.
- There is a $10.00 monthly maintenance fee in lieu of standard dues. If a member has a paid in full membership, the expiration date of the membership will be extended by the duration of the freeze, and we will collect the maintenance fee of $10.00 per month up front.
- Freeze periods are for a minimum of 30 days and maximum of 120 (all freezes are for consecutive days) per membership year. All freeze periods begin at the first of the month and are for full months.
- All memberships that are on freeze will automatically be reactivated at the end of the freeze period without notice to the member.
- If a member returns to the BCC earlier than expected they may see Cindy to pay prorated dues and reactivate their membership at that time.
I authorize my membership to freeze and unfreeze per the below dates.
Membership Freeze Begins *

Month Day Year
Membership Freeze Ends *

Month Day Year
I have read and understand the policies for freezing my membership and agree that the above information to freeze my membership is both accurate and binding. I understand that I must pay the monthly fee of $10 per month, in order to process this request. BCC Staff will contact you to arrange payment, or you may call the BCC at 763-200-4271, to process payment over the phone.
Member Signature *

Clear
Today's Date *

Month Day Year
Should be Empty:

BECKER COMMUNITY CENTER

I authorize my membership to freeze and unfreeze per the below dates.