Member Change Form - Ymca Of Northwest Florida
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1YMCA OF NORTHWEST FLORIDA
MEMBER CHANGE FORM
Staff Initials _____
Member Name: ____________________ Member #:_____________ Date: _________
I wish to make the following change to my membership:
Section 1: Name Change
Old Name _____________________________
New Name ________________________________
Section 2: Contact Information Change
Street ___________________________ City _______________________
State ______ Zip
___________
Email 1: __________________________ Email 2: ____________________________
Receive Texts? Y / N
New Contact Number (s): Home: __________________ Work: ________________ Cell: ________________
New Emergency Contact: Name: _________________ Cell: _________________ Relationship: ____________
Section 3-Circle One:
MEMBERSHIP CHANGE - ANNUAL RENEWAL- HOLD / CANCEL RELEASE
Change my membership type from ____________________________________ ($ ___________) to
_________________________________ ($ ______________) effective date of ______________
Please ADD/RENEW/REMOVE (circle one) the following family member(s):
Name(s) & Date of Births
_________________________________
_________________________________
_________________________________
_________________________________
1
st
15
th
Section 4: Change Draft Date-Circle One:
Section 6: Bank Change
I authorize my bank or credit card institution to honor preauthorized Electronic Funds Transfer drawn by the YMCA of
Northwest Florida on my account for membership payments as indicated. When the bank honors the EFT (or
credit/debit card) by charging my account, such transfer shall constitute notice of payment due and my receipt for the
payment. This authority is to remain in effect until such notice is given to both the YMCA and my financial institution
of intent to revoke the agreement in compliance with YMCA policy; this membership will be continuous until
written notification has been received by the YMCA of NW Florida at least 3 days before the said draft
date. The YMCA of NW Florida reserves the right to increase membership rates annually at a rate consistent with the
rate of inflation. If, at any time, there is to be a change, deletion, or cancellation of membership, it is to be
submitted in writing to the branch YMCA where membership was purchased along with membership
card(s) no less than 3 days prior to the draft date. Failure to do so will result in that month’s draft being
non-refundable. Members have up to 90 days to dispute drafted membership dues. Staff will require printed
proof of an alleged discrepancy to pursue the issue.
-------------------------------------------------------------------------
Change Credit Card Information:
____________________________________________________
___ Visa ___ MasterCard ___ Discover Last 4 digits: ________ Exp: ____/____
: ____/____
Update exp. only
EFT Change: Last 4 digits Routing #:_____ Last 4 digits Account #: _____ Checking
Savings
Annual Charitable Campaign Contribution: $5
$10
$20 Other: ____ Donation Start Date_______
*Charitable contributions draft monthly along with your membership dues*
Signature below authorizes the YMCA of Northwest Florida to make the above changes to my membership
account. Failure to cancel my draft 3 days prior to my draft date will result in that month’s draft being non-
refundable.
________________________________________________________________________________
Signature of Member
Date
Member Change Form 10/2015
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