Membership Downgrade Form
This form has been prepared to ensure compliance with the Privacy Act 1993. The form is between the Member whose details are on the first page (you) and The Garden Pole Dance Studio trading as The Garden Pole Dance Studio at Hyde Park Complex, Unit D7/61 Marsden Street, Melling, Lower Hutt 5010. The information collected is stored securely, is not disclosed to third parties without Member’s consent and will be destroyed when the Membership is terminated.
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Personal Details
Name
*
First Name
Last Name
Phone Number
*
-
Email
*
example@example.com
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Membership Details
Which Membership type are you currently on?
*
Cobra
Python
Anaconda
Have you completed the initial term of your membership?
*
Yes
No
Which Membership type would you like to downgrade to?
*
Cobra
Python
Anaconda
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Downgrade Details
Members can downgrade their membership at the end of the initial membership term.
Please downgrade my membership from this date (we require at least 5 business days notice)
*
-
Day
-
Month
Year
Date
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Conditions
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: