Edwardsville Ymca - Membership Cancellation Form
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1EDWARDSVILLE YMCA
MEMBERSHIP CANCELLATION FORM
DATE: ____________________________
LAST NAME: ___________________________________________________________________ FIRST NAME: ____________________________________________________
ADDRESS: ______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
PHONE: ____________________________________________________
EMAIL: _______________________________________________________________________________
Please answer the following questions to help us ensure the future quality at the Edwardsville YMCA:
1. Which of the following best describes your reason for leaving the YMCA? (select all that apply)
_______ Used facilities less than anticipated
_______ Relocation
_______ Medical
_______ Joining another club/facility
_______ Financial reasons- Would you like financial assistance information? _________________________________________________________
_______ Dissatisfied - If so, please provide reasons: _______________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
2. SELECT YOUR RATING FOR EACH CATEGORY.
VERY
VERY
SATISFIED
NEUTRAL
UNSATISFIED
SATISFIED
UNSATISFIED
STAFF
5
4
3
2
1
FACILITIES
5
4
3
2
1
PROGRAMS/SERVICES
5
4
3
2
1
HOURS
5
4
3
2
1
WEBSITE
5
4
3
2
1
DISTRIBUTION OF INFORMATION
5
4
3
2
1
(CATALOG,FLYERS, SOCIAL MEDIA, ETC.)
OVERALL EXPERIENCE
5
4
3
2
1
ADDITIONAL COMMENTS:
3. What improvements would you like to see at the Edwardsville YMCA? ______________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
4. Would you like to be contacted by the membership director? YES NO (If yes, select method) Phone Email
It is my understanding that it will require 14 days for my bank draft to be cancelled, and that there may be one additional
draft from my account. If I stop payment or it is returned due to insufficient funds, I will be charged for that payment plus
any service charges incurred by the YMCA. I further understand that membership cards must be returned. By cancelling or
allowing my membership to expire for more than 30 days, I realize that if I rejoin, I will be reassessed the joiner fee. I will be
provided a copy of this form, and it will serve as my verification of cancellation. _________initial
Member Signature: _______________________________________________________ Staff Signature: _______________________________________
FOR STAFF USE ONLY
Please look up in CCC and verify the Billing member for this cancellation.
Date of last bank draft will be: ________________
_____________________________________________________________________________
Membership effective through: ________________
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Parent category: Business