Contact Name Email Phone Birthdate:* Home YMCA Facility: Reason for Cancellation: --None-- Cleanliness Cost Customer Service Concern Dissatisfied with Gym Equipment Lack of Usage / Programming Limited Child Watch Hours Medical Military Deployment Never Got Started Operating Hours Program Dissatisfaction Relocation Safety Concern Seasonal Using Another Gym or Home Equipment Cancellation Person to Remove: Cancellation Additional Information: I understand changes to my membership account must be received by the 25th day of the month in order to ensure no charges will take place in the following month. If a membership lapses for more than 30 days, a rejoining fee will apply. Yes, I acknowledge the above hold statement pertaining to my cancellation request. *