Cancellation Form

Primary Member Name*

First NameLast Name

Primary Member UIN*

Primary Member Email*

Confirmation EmailConfirm email

Membership Type*

AlumniCommunity/Community LimitedUIC Faculty/StaffIllinois Medical District (IMD)

Type of Cancellation*

Payroll Deduction (UIC Faculty/Staff ONLY)EFT (Electronic Fund Transfer)

Select ALL memberships you are cancelling*

Member 2*

Member 2 NameMember 2 UIN

Member 3*

Member 3 NameMember 3 UIN

Member 4*

Member 4 NameMember 4 UIN

Member 5*

Member 5 NameMember 5 UIN

Member 6*

Member 6 NameMember 6 UIN

Recreation and Wellbeing Cancellation Policy

Members paying by EFT or Payroll Deduction have no expiration date and will continue until a completed Membership Cancellation form is received. There is a $50 cancellation fee (per membership) if the cancellation is made before the sixth monthly EFT transfer or 12th bi-weekly/6 monthly payroll deduction (not including the pro-rate). A minimum of 6 monthly EFT/payroll or 12 bi-weekly payroll transfers is required. The $50 early cancellation fee must be paid in full at the time of cancellation. (If all individuals within a family membership cancel at the same time, a $100 early cancellation fee will be assessed.)

A 30 day advance notice is required for all cancellations. EFT cancellation requests will be processed in the following manner:

Cancellations received on the 1st – 15th of the month: Memberships will terminate at the end of that month and automatic withdrawals will stop with that month’s payment.

Cancellations received on the 16th – the end of the month: Memberships will terminate at the end of the following month and automatic withdrawals will stop after the following month’s payment.

Phone calls will not be accepted as a form of cancellation. Members will be contacted via e-mail once the form has been received and processed. If you do not receive an email confirmation, please contact us at uicrec@uic.edu.

UIC Faculty/Staff that will be retiring or leaving their employment for any reason must submit a membership cancellation.

I agree to UIC Recreation and Wellbeing cancellation policy.

Signature*