Membership Leave of Absence Request
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E-mail
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Area Code
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Street Address
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Reason for Leave of Absence
*
Travel
Medical
Military
Concerns Regarding Coronavirus Impact
Other
For draft members, a freeze begins with an upcoming draft date and ends the day before a draft date. A freeze can be for one, two or three months. Any additional adjustments to this freeze will also require 30 days written notification.
Length of Leave of Absence
*
1 Month
2 Months
3 Months
Other (requires approval by Membership Leadership Team. Please specify the length of time and why in comments below)
Comments:
By signing (typing) my name below, I acknowledge that I am the primary account holder of the membership and that the above information is correct. I understand that it will require 15 days to affect my bank draft and I am responsible for any payments within the 15 day period. I understand that my draft/invoice will automatically renew after my freeze end date and a confirmation of that specific date will be sent to the email address provided above. I will not have access to the YMCA and will receive the program participant rate for all programs until that date.
*
Staff Use Only:
Freeze begin date(must match current drafting schedule)
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Freeze end date (date draft/invoice will resume):
*
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Member #
*
Employee signature
*
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