YMCA at ACRC TERMINATION FORM

We are sad to see you go! Please complete this form to terminate your Membership at the YMCA at ACRC.

MEMBER INFORMATION

Date of Birth * +

Gender *

Female

Male

Unspecified

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number (including area code) *

Email Address *

REASON FOR TERMINATION

*

I am dissatisfied with the YMCA at ACRC. To allow us the opportunity to improve, please list your dissatisfaction: I am dissatisfied with the YMCA at ACRC. To allow us the opportunity to improve, please list your dissatisfaction:

What could the YMCA at ACRC change that would make you reconsider terminating your membership? *

MEMBERSHIP TYPE

*

WOULD YOU LIKE US TO CONTACT YOU?

We are sad to see you go. If you have more questions or would like us to contact you, please check "YES".

*

Yes

No

TERMINATION AGREEMENT

Today's Date * +

TERMINATION AGREEMENT
I understand that the YMCA at Austin Community Recreation Center required two full months of membership dues before terminating. I must terminate my membership by the 26th of the month in order to cancel my membership for the next month and stop the automatic debit/credit transfer of funds. My membership fees are non-refundable and I will be charged for the months I was a member even if I didn’t use my membership. By choosing to terminate my membership, I will have to pay the joiner fee if I decide to reapply for membership if more than 30 days have passed. Canceling my membership will result in forfeiture of any unapplied insurance reimbursement. I will be responsible for any outstanding balances before I am able to cancel my membership. *

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Drop for season	Financial Assistance	Medical reasons
Monetary difficulties	No longer using facility	Purchased home equipment
Relocation	Switching to another facility