Membership Upgrade 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
Which Membership type would you like to upgrade to?
*
Cobra
Python
Anaconda
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Upgrade Details
Upgrading your membership can happen at any time during your membership term
Please upgrade my membership from this date (we require at least 5 business days notice)
*
-
Day
-
Month
Year
Date
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Administration Fee
$30.00 NZD per month or part month for the Freeze period (e.g. A 6 week freeze incurs a $60 fee)
Would you like us to charge the administration fee to the payment method we have on file for you?
*
Yes
I'd like to provide a different payment method (we will contact you to arrange)
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Conditions
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: