Membership Freeze Form

Membership Freeze Form
Name of Member
Today's Date

MonthDayYear
Date
Membership Number
Phone Number
Format: (000) 000-0000.
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
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
Should be Empty: