Membership Cancellation Form
30-Day Cancellation Notice
Member Name
*
First Name
Last Name
Parent or Legal Guardian, if applicable
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Reason for Cancellation
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Medical
Re-location
Non-usage
Finances
Other
Please, explain the reason why you are requesting to cancel your membership.
*
Rate Your Overall Experience at Gracie Barra (1 is poor, 5 is great)
1
2
3
4
5
Any comments or suggestions that would help improve the quality of our services?
Per the terms of my membership agreement, I am providing Gracie Barra Santa Barbara 30-day notice to cancel my membership. I understand that I am responsible for one final payment, that will be automatically processed within 30 days from the date this membership cancellation notice is submitted. I understand that my membership will remain active until the final payment is received.
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I understand the cancellation policy.
I understand that once my membership is cancelled, I will need to purchase a new membership, at the most current membership rate, in order to start attending classes at Gracie Barra again at anytime. I am also aware that I will be charged a $50 enrollment fee to reinstate my account.
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I understand.
Unless specified otherwise, I understand that the final payment will be processed according to my billing cycle schedule, as disclosed on my membership agreement.
*
I would like my final tuition payment to be processed now instead.
I would like my final tuition payment to be processed on my next billing cycle.
Member/Parent or Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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