HomeMy WebLinkAboutMembership Change FormO'Brien / YMCA Partnership
Membership Change Form
Name DOB
Phone Email
Address
Only update address if you’ve moved in the last three years.
Signature Date
Please note: All changes must be made before the 1st of the month.
Desk Staff Member ID Date OFFICE USE ONLY
— OR —
Bank Draft - Attach voided check
Checking Savings
Last 4 digits of account number
Routing Number
Credit/Debit
Card Holder
Last 4 digits of card number
Expiration Date /
Update Billing
I understand and agree to: (please initial each line)
This EFT agreement allows the YMCA of Greater Michiana to automatically charge my account on the 10th of
each month, or shortly thereafter for membership, or immediately for one time fees associated with programs.
I understand that the YMCA of Greater Michiana membership fees will continuously withdraw from my
account each month until written cancellation is received. All cancellations are pending current months payment.
Cancellation of membership must be given in writing by the primary member or account holder. I will be
responsible for all balances prior to the termination date. Non-usage does not mean automatic cancellation.
The YMCA of Greater Michiana has the right to increase membership fees with a 60-day written notice.
Declined credit cards for membership fees will be attempted up to 3 more times through our collection
department. Bank drafts/EFT returns will have a $15 return fee. Returned checks will have a $20 return fee. All
memberships not paid by the 25th of the month will be charged a $15 late fee and will be suspended.
Memberships inactive for more than 30 days will be subject to the joiner fee.
Add/Remove Member
Current Membership Type New Membership Type
Name Birthday Male / Female Add / Remove
Name Birthday Male / Female Add / Remove
Name Birthday Male / Female Add / Remove
New Monthly Draft $