Membership Freeze Form

Membership Freeze Form
Name of Member
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Membership Number
Phone Number
Format: (000) 000-0000.
Requested Freeze Dates:
Start Date of freeze

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date of freeze

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
File Upload

Cancelof
Should be Empty: