Membership Cancellation 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.
Back
Next
Personal Details
Name
*
First Name
Last Name
Phone Number
*
-
Email
*
example@example.com
Back
Next
Membership Details
Which Membership type are you currently on?
*
Cobra
Python
Anaconda
Have you completed the initial term of your membership?
*
Yes
No
Back
Next
Cancellation Details
Members can cancel their membership at the end of the initial membership term without paying a cancellation fee. Cancelling during the initial membership term will require a cancellation fee and six (6) weeks notice.
Please cancel my membership from this date (we require at least 5 business days notice)
*
-
Day
-
Month
Year
Date
Back
Next
What is your reason for cancelling?
Please Select
Medical / injury / illness
Financial reasons
Timetable doesn't work for me
Relocation
Other
Do you have any feedback for us?
Would you like to complete an anonymous survey about your experience at The Garden?
*
Yes
No
Back
Next
Conditions
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: