HomeMy WebLinkAboutMembership Discontinuation FormO'Brien / YMCA Partnership
Membership Discontinuation Form
Primary Member
Address
City State Zip
Email Phone
Check here if you are enrolled in payroll deduction. Company
Check here if you would like to keep your monthly donations to our annual campaign.
Reason for Discontinuation
Dissatisfied We value your feedback. Please let us know how we can improve below in the comments.
Financial Did you know we offer financial assistance?
Seasonal Did you know you can put your membership on hold?
Medical Did you know you can put your membership on hold?
Moving/Relocating We’re sad to see you go. Let us know if we can help you locate a YMCA in your area!
Non-Use/Time We get it – life gets busy sometimes. We will be here when you are ready to get back at it!
Joined Another Facility We’re sorry to see you go, but we’re glad to see you continue to improve your health. Let us know
what we can do to change your mind in the comments.
New facility:
Feedback/Comments:
I understand that I am responsible for the current month’s membership dues and any outstanding balances.
Signature Date
You will be made inactive after the last day of the current month. You’re welcome to utilize full membership benefits
until then. This month’s payment will draft on the 10th.
Desk Staff Member ID Final Draft OFFICE USE ONLY
DATE: