HPD Membership Cancellation Request Form

FITNESS MEMBERSHIP CANCELLATION REQUEST
Today's Date

MonthDayYear
Date
Member Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Email*
example@example.com
Primary Phone*
Home Phone
Name(s) of Additional Members to be cancelled:
Other fitness members within household who are cancelling their memberships as well.
Other Membership options to be cancelled

Childcare
If Other Membership options are selected, please list all applicable names:
Separate names using a comma (,)
Please tell us why you are choosing to cancel your membership (check all that apply). *- With proper documentation, cancellation fee may be waived.*

Do Not Use EnoughCannot AffordEquipment/Amenities*Relocation (must provide proof of new address [i.e. utility bill, updated driver's license, rental/lease agreement, or letter from employer stating relocation] - Attach below)Joined Another Facility*Medical (must provide Doctor's note - Attach below)
Medical Doctor's Note Upload

Cancelof
Relocation Upload

Cancelof
Terms of Cancellation

Fully completed and submitted Cancellation Requests received on or before the 25th of the month will be processed before the next billing date. Cancellation Requests received after the 25th of the month will be processed in the following month, which will include all billing amounts and an active membership through the upcoming month.

Monthly Memberships
Per the contract terms stated on the membership application signed at the start of your membership, a cancellation fee of $10 per month will be charged towards the number of months remaining on your initial 12-month contract. Upon review, and following communication sent by HPD staff, you will have the opportunity to pay any cancellation fees by visiting the Registration Office of the REC Center. If you do not pay in-person by the end of the month the cancellation request has been made, then your linked payment method will be billed in the amount of your cancellation fee on the 1st of the next month. After your cancellation fee has been paid, your membership cancellation will be processed.

I consent to these Cancellation Terms and agree to any fees mentioned above in order to terminate my Fitness Membership with Huntley Park District.

Completing this form does not mean your membership has automatically been processed. This form is simply a cancellation request, which will be reviewed by HPD Staff prior to processing your cancellation. If cancellation fees are required, you will be contacted by email from HPD staff. Your membership will not be cancelled until paid. In any situation, a confirmation email/receipt will be emailed to you after your cancellation has been approved and processed.
Member Signature*

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

FITNESS MEMBERSHIP CANCELLATION REQUEST