Salina Membership Cancellation Form

1
Member information* This field is required.
Member full name
Date of birth
Primary phone number
Email address
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Please Select
Adult membership
Couple membership
Family membership
Student membership
Young Adult membership
YMCA360 membership
Youth membership
Type of membership
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Please Select
Yes
No
Did you have Kids Gym access?
2
Address* This field is required.
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Is this a Corporate Membership?* This field is required.
YESNO
4
Employer* This field is required.
5
Why are you cancelling your YMCA membership?* This field is required.Please select all that apply.
I experienced a change in employment or job loss
I do not use my membership
Family emergency
Joined other facility
Medical reasons
I moved
I can't afford it
I had a seasonal membership
Due to a rate increase
I'm too busy
I'm dissatisfied with my membership
Other
6
What other facility did you join?* This field is required.
7
You indicated you are cancelling your YMCA membership due to financial reasons. Would you like more information about financial assistance?* This field is required.
YESNO
8
Please explain why you are dissatisfied with the YMCAYour answer helps us improve the quality of our organization.
9
What did you like about your YMCA experience?
10
How could we have better met your needs to help you achieve your goals?
11
Would you rejoin the YMCA?
YESNO
12
Please rate the cleanliness of our facility
1
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4
5
Poor
Excellent
13
Please rate the communication to members
1
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3
4
5
Poor
Excellent
14
Please rate the staff's knowledge
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3
4
5
Poor
Excellent
15
Please rate the friendliness of the staff
1
2
3
4
5
Poor
Excellent
16
Please rate the amount of equipment
1
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3
4
5
Poor
Excellent
17
Please rate the value for the price
1
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3
4
5
Poor
Excellent
18
Please rate the quality and variety of programs
1
2
3
4
5
Poor
Excellent
19
Please rate the hours of operation
1
2
3
4
5
Poor
Excellent
20
Please rate the access to staff members
1
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4
5
Poor
Excellent
21
Membership draft acknowledgement* This field is required.
Should be Empty: