Membership Freeze Form
This form has been prepared to ensure compliance with the Privacy Act 1993. The form is between the Member whose details are on the first page (you) and The Garden Pole Dance Studio trading as The Garden Pole Dance Studio at Hyde Park Complex, Unit D7/61 Marsden Street, Melling, Lower Hutt 5010. The information collected is stored securely, is not disclosed to third parties without Member’s consent and will be destroyed when the Membership is terminated.
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Personal Details
Name
*
First Name
Last Name
Phone Number
*
-
Email
*
example@example.com
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Membership Details
Which Membership type are you currently on?
*
Cobra
Python
Anaconda
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Freeze Details
Your membership can be frozen from 4-8 weeks. Memberships can only be frozen in full weeks.
What is the reason for your membership freeze request?
*
Day membership is usually charged
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please freeze my membership from (Ensure this is a date your membership payment would normally be deducted, we require 7 days notice)
*
-
Day
-
Month
Year
Date
for
*
4 Weeks
5 Weeks
6 Weeks
7 Weeks
8 Weeks
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Administration Fee
$30.00 NZD per month or part month for the Freeze period (e.g. A 6 week freeze incurs a $60 fee)
Would you like us to charge the administration fee to the payment method we have on file for you?
*
Yes
I'd like to provide a different payment method (we will contact you to arrange)
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Conditions
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: