Membership Status Change Form

YMCA of Collier County

Membership Status Change Form
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Home Branch (please select one)*

North (Naples)South (Marco Island)
Membership Change Requested*

TerminationHold/PauseMembership Type Change
Reason For Cancellation

CostDid Not UseDissatisfiedMovingSeasonalMedicalOther
If cancelling due to financial burden, would you be interested in our financial assistance program?

YesNo
Cancellation Policy: A 30 day notice is requested to cancel your membership effective immediately or at the end of your current pre-paid monthly billing cycle. No refunds will be given for any unused portion of your last month of paid membership. Note that we never refund membership fees due to lack of use or non-attendance. Joining fees are non-refundable. This cancellation policy is for membership only and does not automatically cancel any current or upcoming program registrations. Cancellations and refunds for youth programs, sports, camps, swim lessons, and specialty offerings are subject to a separate cancellation and refund policy.
Membership Change Request:
Please detail in the box above what changes you are looking to make to your current active account. (ex. add/remove member, alter membership type, etc.)
Membership Hold

Holds begin on the last day of each month and restart on the 1st following its conclusion

*Allowed for up to 3 months, once a year*
Hold Start Date:
From: Date
Length of Membership Hold

1 Month2 Months3 Months
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
I understand that the YMCA of Collier County requires a Membership Status Change Form to be completed by me to make any changes to my membership, including stopping my vank draft. I understand that if my membership dues are withdrawn on the 1st of the month, my Status Change form must be recieved by the YMCA 31 days in advance. I also understand that should I choose to rejoin within 90 days of cancellation, I will not be required to pay an additional joining fee. However, if I choose to rejoin after 90 days, I will be required to pay the joining fee, if applicable.
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YMCA of Collier County