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O'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 $