AUSA Blueprint Freeze Request Form

Blueprint Freeze Request Form
Form Completion Date*

DayMonthYear
Members Home Facility*
Program*
Members Full Name?*

First NameLast Name
Members Email*
MUST be the email associated with your account.
Members Mobile*
Thanks. Would you mind sharing the reason for your Freeze Request?*

FinancialLack of MotivationHolidayLack of TimeWork/StudyOther
Select the Monday from which you want your freeze to start?*

DayMonthYear
If you select a Monday during a non billing week, we will set to the following Monday.
Length of Freeze (in weeks)*
*Freezing extends the minimum commitment period.
*You are entitled to 4 weeks of complimentary freezes per year.
*Minimum duration of a freeze is 1 Week and runs Monday to Monday.
By signing here, I acknowledge that my membership may be frozen for a minimum of 1 week and a maximum of 4 weeks, and the freeze must cover the entire billing period. I understand that I will not be able to use any venue during the freeze period, and the freeze will pause the calculation of my Initial Commitment Period. No freeze fee applies. I also acknowledge that if I am found using the facility while my membership is on freeze, I will be fined $50 per visit.*

Yes
Signature

Clear
Any additional information you'd like to share about your freeze?
Should be Empty: