Membership Cancellation Form - Ymca Of Callaway County printable pdf download

Membership Cancellation Form - Ymca Of Callaway County

YMCA OF CALLAWAY COUNTY

Membership Cancellation Form

FIRST NAME

LAST NAME

DATE OF BIRTH

PHONE NUMBER

EMAIL ADDRESS

REASON FOR CANCELLATION - PLEASE SELECT ALL THAT APPLY.

□ NO LONGER USING FACILITY, please select a reason: ______ no time; _____ lack of motivation; _____ other

□ MEDICAL REASONS - DID YOU KNOW YOU CAN PUT YOUR MEMBERSHIP ON HOLD? _______________________________

□ RELOCATING

□ FINANCIAL REASONS—Have you considered our OUTREACH PROGRAM? _________________________________________

□ JOINED ANOTHER FITNESS CENTER: where? ______________________________________________________________

□ SEASONAL— DID YOU KNOW YOU CAN PUT YOUR MEMBERSHIP ON HOLD? ______________________________________

□ DISSATISFIED— PLEASE EXPLAIN:_______________________________________________________________________

PLEASE READ AND SIGN BELOW:

It is my understanding that cancellations must be received by the LAST DAY of the month for my draft to be

cancelled; any cancellations after the LAST DAY of the month will result in one final draft on my account.

If I stop payment on the final draft, I will be charged the service charges incurred by the YMCA of Callaway County. By

cancelling, or allowing my membership to expire, I realize that my joining fee is non-transferable after 60 days. The YMCA

of Callaway County cannot give refunds or credits unless you have proof of cancellation.

PLEASE RETAIN A COPY FOR YOUR RECORDS.

MEMBER SIGNATURE: ______________________________________ DATE: _______/_______/________

STAFF SIGNATURE: ________________________________________ DATE: _______/_______/________

MEMBER SERVICES USE ONLY:

DATE FORM WAS RECEIVED ___/___/___

DATE OF LAST DRAFT ___/ 05 /___

□ RECONCILED ANY BALANCE ON ACCOUNT

□ DELETED BILLING METHOD ON ACCOUNT

□ DAY TERMINATION WILL TAKE EFFECT: ___/___/___

STAFF INITIALS: _______

VERIFIED BY: _______

□ YELLOW COPY GIVEN TO MEMBER

DATE REVIEWED: ___/___/___

Membership Cancellation Form - Ymca Of Callaway County