Membership Freeze Form

Membership Freeze Form
Name of Member
Today's Date

MonthDayYear
Date
Membership Number
Phone Number
Requested Freeze Dates:
Start Date of freeze

MonthDayYear
Date
End Date of freeze

MonthDayYear
Date
Please note that you are required to give 30 days notice and there is a $5+tax biweekly freeze rate on all membership freezes. Reason for Freeze?
Has a Doctors Note been provided for a medical membership freeze?
Member Signature

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Today's Date

MonthDayYear
Date
Attention! Signing this form does not guarantee approval. It is the first step in informing us of your request. Your account remains active until you receive a confirmation email or a call from us, notifying you of the approval or denial. Member Acknowledge Signature:
Member Acknowledge Signature

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Should be Empty: