Countryside YMCA Program Withdrawal
Please note this form must be received by the 20th of the month to stop automatic payments for the next month.
Participant's Name
*
First Name
Last Name
Your Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
E-mail
*
example@example.com
Location
*
Please Select
Lebanon
Landen
Program
*
Please Select
Swim Lessons
Gymnastics
Volleyball
All About Sports
Soccer
Fencing
Tae Kwon Do
Climbing Wall
Speed and Agility
Intro to Golf
KidFit
Judo
Personal Training
Arts & Education (Specify in additional info)
Other (Please note class in additional info)
Class Name
*
Day and time of class
*
Indicate reason for cancellation
*
Please Select
Schedule Change
No longer interested in program
Financial
Other
By typing my name below, I understand my automatic payments will stop and I will be removed from my current class.
*
Additional Information
Submit Cancellation
Should be Empty: