Cancellation Form

Cancellation Form
This electronic version of a cancellation form must be submitted 5 days prior to the month in which you want to cancel your membership. Please refer to our cancellation policies for more information.
Main Member Name*
First Last
Member ID #*
Number on your Key Tag or Moraine ID
Email Address*
Phone*
Payroll Deduction?*
- Yes
- No
Do you currently have a locker rental?*
- Yes
- No
Are you the only member on the account being cancelled?*
- Yes
- No

Additional Cancellations
Please indicate additional members/services that you would like to cancel
#1 - Member ID
#1 - Name
First Last
Please cancel the following for Member #1:
Highlight all that apply
#2 - Member ID
#2 - Name
First Last
Please cancel the following for Member #2:
Highlight all that apply
#3 - Member ID
#3 - Name
First Last
Please cancel the following for Member #3:
Highlight all that apply
#4 - Member ID
#4 - Name
First Last
Please cancel the following for Member #4:
Highlight all that apply
#5 - Member ID
#5 - Name
First Last
Please cancel the following for Member #5:
Highlight all that apply
#6 - Member ID
#6 - Name
First Last
Please cancel the following for Member #6:
Highlight all that apply
Please list Member ID, name, and services you wish to cancel of any members not listed above.

Reason for Cancelling
We are sad to see you go! Please let us know why you are leaving FitRec.
Reason for Cancelling*
- Separation from Moraine Valley
- Moving
- Joining Another Gym
- Lack of Use
- Medical Reason
- Enrolled in classes
Cancellation Comments

Cancellation Agreement
By initialing next to each line, this indicates you agree with the statement listed.
I understand that the cancellation form must be submitted to FitRec 5 days prior to the month in which I wish to cancel.*
I understand that if the cancellation form is not submitted by the deadline, that I will be billed for the following month and will end at the end of that month.*
I understand my cancellation will not be processed unless I have a zero balance on my account.*
I understand that signing up for an annual or 1-month membership, I cannot freeze, cancel or get a refund for my membership (unless a medical reason).*
I understand that if I am the primary member, that if I cancel my membership, my spouse and/or dependents memberships will end as well*
Or a sub member will become the main member if you wish to do so.
I understand my locker must be cleaned out prior to my membership expiration date.*
Community – I understand that I must maintain my membership for at least 6 full billing months to avoid a $40 cancellation fee.*
I understand there is a $40 fee (per change) for any additions or swapping of any sub-members on a family membership.*
Payroll Deduction Only – I understand that due to payroll processing that my deductions may not end immediately.
Signature
By typing your full name below, you understand the cancellation policies and a staff member will contact you if there are any questions regarding your account.*
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Additional Cancellations