Membership Cancellation Request Form

Membership Cancellation Request
Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Email
example@example.com
What is the main reason for cancelling your membership?

Slow to UnderstandingCant attend the meetingsRelocationLack of MotivationOther
On a scale of 1-5 (5 being the highest), how do you rank your overall experience at Strong Minds?
Be Kind
What were your desired goals when you joined Strong Minds?
Did you meet those goals?

YesNo
How would meeting those goals have impacted your life as it is today?
Did staff provide a good customer experience?
Did you find your staff knowledgeable?

We want your input!

	Definitely	Probably	Not Sure	Probably Not	Definitely Not
Will you use our service in the future?
Will you recommend our service to others?

How can we improve our programs or services?
I hearby certify that I wish to cancel my membership with Anytime Fitness. I understand that my account must be in good standing in order to complete this requst. I understand that I am responsible for any billing that will occur within the next 30 days. I understand I will be provided a copy of the Member Cancellation request via email.
Name

First NameLast Name
Signature

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Cancel Date:

MonthDayYear
Date
Payment Balance (30 Days After Cancel Date)
Membership End Date

MonthDayYear
Date
Last Usage Date
Consultation Offered

YesNo
Options Offered
Active OS Agreement

YesNo
Additional Notes
Anytime Fitness Rep

First NameLast Name
Should be Empty:

Membership Cancellation Request