Name *

First Name

Last Name

Phone *

(###)

###

####

Date You Would Like to Cancel *

MM

DD

YYYY

Alternatively, would you like to use your last membership payment towards a discounted 10 class package that never expires at $200 and authorize that my final bill will be $200? *

Yes

No

I understand the 30 day notice cancellation policy and I authorize the account activity outlines above. *

Yes

No