HPD Membership Hold Request

Membership Hold Request
Today's Date*

MonthDayYear
Date
Member Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name(s) to be held*
Please list the FIRST and LAST name of all members that you would like to put on hold at this time. Separate with a comma (,).
Other Membership options to be held (at no charge)

Childcare
If Childcare is selected above, provide name(s) of Childcare Members to be held.
Please list the FIRST and LAST name of each member, and separate with a comma (,).
Monthly Fitness Membership Holds will be charged $5 per month, per person during each month of the hold. Fee is charged to lock in your current membership rate while membership is on hold. A member can put their membership on hold for a maximum of 4 months per any 12-month period.
Reason for Hold*

Travel or Out of Town for extended period of timeNot Utilizing Facility at this TimeUsing an Outdoor Space or Home GymMedical ($5 monthly fee will be waived or refunded as soon as a doctor's note is provided that lists specific dates the member or caretaker is unable to participate due to medical restrictions. Option to upload medical note below.)Other
Medial Note Upload

Cancelof
Months to put on Hold (Maximum of 4 consecutive months)*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Date to Start Hold*

MonthDayYear
Date
Date to End Hold*

MonthDayYear
Date
Member's Signature*
Date*

MonthDayYear
Date
Date Form Completed with Member (Date)

MonthDayYear
Date
Date Form Completed with Member (Initials)
Should be Empty: