Membership Amendment Form

Personal Information

First Name *

Last Name *

Address *

Email Address *

Phone Number *

Membership Number (if known)

Suspensions Terms and Conditions

Suspend for any reason
Minimum of 7 days and a maximum of 28 days
Maximum of 4 weeks suspension available in 12 month period of membership
Medical exemptions available for extended suspension periods
The member’s payments will be re-activated after their suspension period has been completed
A minimum of 7 days written notice is required when requesting a suspension
Membership suspensions cannot be backdated

Suspend from:

Suspend to:

Total number of days:

If Other, please specify:

Cancellation Terms and Conditions

Cancellation from:

If Other, please specify:

Would you like to stay on the YMCA Chifley Health and Wellness Centre's email list:

YesNo

Signed *

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For Office Use Only

Processed by:

Date: