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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
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Gender
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Female
Male
Unspecified
First Name
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Last Name
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Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number (including area code)
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Email Address
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REASON FOR TERMINATION
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COVID-19
Drop for season
Financial Assistance
Medical reasons
Monetary difficulties
No longer using facility
Purchased home equipment
Relocation
Switching to another facility
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?
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MEMBERSHIP TYPE
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Adult
Family
Senior
Senior Couple
Young Adult
Youth
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".
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Yes
No
TERMINATION AGREEMENT
Today's Date
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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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