Wyoming Co. YMCA Membership Termination Form
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First Name *
Last Name *
Home Street Address *
City *
Zip Code *
Primary Phone Number *
Email Address *
Please rate your overall satisfaction with the Y: *
Required
Are you aware that the Y offers Financial Assistance? *
Required
What is your reason for terminating at this time? *
Required
If you were dissatisfied with your membership please tell us why.
Would you like a member of management to contact you regarding your comments? *
Required
What type of Y membership do you currently have? *
Required
Any suggestions or comments that you have that would help make the Y a better place for you and your family?
YOUR CONSENT FOR TERMINATION
I am hereby requesting that the Genesee County YMCA discontinue my membership bank draft. I understand that my draft will be terminated 30 days from the receipt of this notice and that once I cancel my membership, I will be required to pay the membership joining fee should I choose to reinstate my membership after 60 days of termination.

By signing this form, I understand that my account will be drafted one more time if the next payment draft falls within 30 days of completing this request.

By typing my name in the space provided, this is my electronic signature validating my consent of the termination policy of the YMCA.
Consent for termination verification *
Required
Electronic Signature (Type your Full Name) *
Today's Date *
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