Direct Debit Suspension Application Request Form
Select your centre
*
Gungahlin Leisure Centre
Canberra Olympic Pool
Stromlo Leisure Centre
Lakeside Leisure Centre
Membership/Program Type
Gym Membership
Swim School Membership
Full Name
*
First Name
Last Name
Email
*
example@example.com
Mobile
*
0400 000 000
Membership Payment Method
*
Direct Debit
Suspend Membership from
*
-
Day
-
Month
Year
Select Start Date (Please pick a future date)
Suspend Membership to
*
-
Day
-
Month
Year
Select End Date (Please pick a future date)
Reason for Suspension
*
If applicable, attach proof of medical certificate
Browse Files
Cancel
of
I agree to Terms and Conditions
*
By ticking this box I acknowledge that my account will be suspended in line with the T&Cs of my membership. Your membership fee will be reduced to $5.00 during this time for a maximum of up to 6 weeks in total. Regular payments will begin after 6 weeks, or after your suspension end date if less than 6 weeks.
Submit Request
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