Membership Cancellation Request Form

Name*

First Last

YMCA Branch*

Today's Date*

Home/Primary Phone*

Mobile Phone

Date of Birth*

MM

DD

YYYY

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Monthly Draft Date*

The day of the month that your membership dues are drafted from your bank or credit card account. Typically 1st or 15th of the month.

1st of the Month (first)
15th of the Month (fifteenth)
I don't know
This is an annual membership - paid in full

Primary Reason for Cancellation*

Choose one

Additional Reasons for Cancellation (if any)

Choose any additional reasons that apply

COVID-19
Relocating / Moving
Medical
Financial
Joined another gym
No longer using the Y facilities
Unsatisfactory service
Other

Would you like information on donating your membership dues instead of cancelling?*

You may opt to remain a "Meaningful Member" and convert your monthly membership dues to a tax-deductible donation. Our team can provide details.

Yes, please contact me
No, please cancel my membership

How would you rate the cleanliness of our YMCA?*

How would you rate the helpfulness of YMCA staff?*

How would you rate our pool, exercise and program schedules?*

How would you rate our fitness equipment?*

Comments & Suggestions for Improvement*

Consent*

I wish to cancel my South Shore Y membership

I wish to cancel my membership at the South Shore YMCA and discontinue the draft on my bank or credit card account. The YMCA requires 15 days’ notice prior to my next monthly draft date. If this request is received less than 15 days prior to my next draft date, I may be charged one final payment. I understand that I am responsible and will be charged for any outstanding balance on my YMCA account. I am responsible for verifying that the draft on my bank or credit card account has been discontinued.

Membership Cancellation Request Form

South Shore YMCA Membership Cancellation Request