Membership Cancellation Form - Ymca Of Harrison County
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1YMCA OF HARRISON COUNTY
MEMBERSHIP CANCELLATION FORM
Billing Member Name: ________________________________________________________________________________________________________ __________________________
Address: ___________________________________________________________________City: __________________________________State: __ _______ Zip: _______________
Phone: ____________________________________________ Email: __________________________________________________________________ ______________________________
What type of membership do you have? _______ Household _______ Senior _______ Adult _______ Student/Youth
How often did you use the facility? _______ Once a month
_______ Once a week
_______ 2-3 times a week
What was the reason for joining our YMCA? Please, check all that apply:
_______ Get Into Shape
_______ Social
_______ Fitness Programs _______ Use of Wellness Center
_______ Use of Gym
_______ Youth Programs
_______ Affordable Rates
_______ Use of the pool
_______ Use of Walking Track
_______ Other, please specify: ________________________________________________________
What is the reason for canceling your membership? (Please check all that apply)
Deceased
Medical Reasons
Dissatisfaction with Facility Crowding
Monetary Problems
Dissatisfaction with Program Offerings
No Longer Using Facility
Drop for Summer/Winter
Relocation
Equipment Availability
Switching to Another Facility
Hours of Operation
Unsatisfactory Facility
Lost Motivation
Unsatisfactory Service
Please let us know how we can improve our service by expanding on your reason(s) for canceling your membership.
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Please note: All Cancellations must be made by the last day of the month to stop the bank draft or credit card draft for the
next month. Completed form may be mailed, emailed or faxed to the YMCA of Harrison County, but MUST be received by the
close of business on the last day of the month. Did you know you can place your membership on hold for up to 3 months for just $10
a month? Financial assistance is available for certain programs and memberships. Those unable to pay the full fee may apply to receive
sliding-scale assistance through the Open Doors program. Open Doors assistance is granted based on personal need, enrollment
limitation and our Y’s financial resources. Applications are available at the front desk. All information is confidential.
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Member Signature
Today’s Date
YMCA OF HARRISON COUNTY
198 Jenkins Ct. NE, Corydon, IN 47112
F 812 738 0721
Unit #: ____________
MS Staff: ____________
E
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