Membership Cancellation Request Form - Ymca Of Kingston
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1Membership Cancellation Request
The approval of this request is subject to the current cancellation policy of the YMCA of Kingston
Centre:
Wright Crescent
Y West
Membership Sales Staff:
Please list all members to be cancelled:
Date Received:
Name
Participant Number
Staff Initials:
_
If applicable:
Locker #:
_
Please list all members remaining:
Name
Participant Number
Last pre-authorized payment
date:
***Member’s Confirmation:
Name of Person Paying for the Membership:
____________________
____
Reason for Request
Moving
Joined another facility
Student returning home
Medical reasons
Financial
Not using the membership
Problem with facility: (please specify)
IF MEMBERSHIP WAS PAID IN FULL:
(one payment) any unused portion of your membership fee, may be: (choose one)
Credit on Account
Refund (Payer please confirm address)
Donate unused portion to the Y
*
_____ Donation receipt requested for income tax purposes
Refunds will be provided within 2 weeks
__________________________________
__________________________________
__________________________________
PLEASE NOTE:
1.
Course privileges cease with cancellation of membership.
2.
All donations receive a charitable donation receipt if requested.
3.
Activation fee will be waived if rejoining within 6 Months.
4.
***Continuous memberships are not refundable. Cancellation must be made prior to the first of the month
in order for that month’s payment to be cancelled, as per membership agreement.
I understand that the approval of this request is subject to the current cancellation policy of the YMCA of Kingston.
Signature:
Date: _________________________________
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