2025 MMA Request for Cancellation of Membership

Mozhdeh Martial Arts - NZ

Request for cancellation of membership
Athlete Information
Athlete’s name*

First NameLast Name
Birth date

DayMonthYear
Request for cancellation

Note: My membership can be cancelled with 21 days notice. I am welcome to re-enrol with Mozhdeh Martial Arts in future, subject to availabilty of a space in class.
I would like to:

Cancel my membership (21 days notice required)
Optional - The reason for my cancellation request is:

I am moving out of the areaI am choosing to focus on a different sport or activityThe cost of classes is too high for meThe timing of classes does not suit meI have an injury or other medical conditionI am not enjoying the classesOther
The date of my last class will be:
Date
Contact details (for parent/guardian if under 18)
Mobile Number*

eg 021Phone Number
E-mail
example@example.com
Name of parent / guardian if athlete is under 18

First NameLast Name
Confirmation

By clicking "submit form" below I authorise Mozhdeh Martial Arts to cancel my direct debit with 21 days notice. I am welcome to re-enrol in future, subject to availability of spaces in class.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Mozhdeh Martial Arts - NZ