Membership Action Form

Membership Action Form
Membership Tag Number:*
I,blanks*, hereby authorise the following changes to be made to my membership and, if applicable, my existing contract with DebitSuccess, and I understand that changes to my direct debit payments will only be implemented prior to the next debit date if received at least 3 working days prior to that date.
Date:*

DayMonthYear
Date
Signature:*

Clear
Suspensions

Standard: min 2 weeks - max 8 weeks | Medical: min 5 days - max 3 months
Start date:

DayMonthYear
Date
Planned date of return to LLC:

DayMonthYear
Date
Reason:

HolidayMedical (min: 5 days - max: 3 months)Other
Payment:

$24 fee to be paid$0 - Medical Certificate attached$0 - Senior's Suspension (max 1 per membership)
If required, please click the button below to upload your medical certificate:

Browse Files

Cancelof
Updated bank account details
Financial Institution Name:
Account Name (name of account holder):
BSB:
Account number:
Updated credit card details
Card type:

MastercardVisa
Name on card:
Credit card number:
Card expiry:
CCV:
Membership Upgrade/Downgrade or Change of Membership
Current Membership:

Aquatic onlyGym onlyGroup Fitness onlyFull access
Desired Membership:

Aquatic onlyGym onlyGroup Fitness onlyFull access
UPGRADES

For Direct Debit Memberships, you will be notified of the new fortnightly instalment amount once processed. For Upfront Memberships, you will be notified of the upgrade price once processed, to be paid at reception. Members are also required to complete a Variation Form for Direct Debit upgrades. Please contact a our Memberships Officer for more information.

DOWNGRADES

No monetary refund will be given and Direct Debit instalment amounts will not be reduced. Instead, bonus days equivalent to the difference in value will be added to the remaining time of the membership.

Please allow up to 14 business days for processing.
Change of personal details
Previous name:

First NameLast Name
Current name:

First NameLast Name
New email:
example@example.com
New address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New phone (home):
New phone (mobile):
New phone (work):
Should be Empty:

Membership Action Form

Suspensions

Updated bank account details

Updated credit card details

Membership Upgrade/Downgrade or Change of Membership

UPGRADES

Change of personal details