Membership Cancellation Form – 30 Day Notice Your account will be canceled 30 days after submission of this form. We will cancel your draft automatically. A copy of this cancellation will be emailed to you for your records. Membership Cancellation Form MEMBER FIRST NAME: * MEMBER LAST NAME: * MEMBERSHIP TYPE: * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone Number * EMAIL: * REASON FOR CANCELLATION: * Injury/Illness Location No Longer Convenient Financial Burden Dissatisfaction With Service Other Did you sustain your injury at BRICK? * Yes No Are you unable to participate in our programming? * Yes No Would you like someone to contact you to schedule a complimentary session with a coach to talk through alternatives to group programming until you heal? * Yes No Was this location convenient to work? * Yes No Was this location convenient to home? * Yes No What would make this location more convenient for you? * Please submit a proof of relocation either work or home, scanned piece of mail. Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 1MB Would you like management to contact you with financial assistance options? * Yes No What was your primary program? * How would you rate the programming? * How would you rate the coaching? * How would you rate the community? * How would you rate the atmosphere, music, amenities, etc? * How you rate management? * How would you rate front desk staff? * Please explain: * Contract * By submitting this form, I am giving BRICK my 30 day written notice to cancel my membership. I understand that my membership will be canceled 30 days from the date this form was submitted. I understand that I will be charged/debited one additional month, for the use of the facility during my 30 day cancellation period. Upon completion of the 30 day cancellation period, my membership shall then be considered terminated. Should I choose to rejoin BRICK after the termination of my membership, I will have to pay at the then current rate. Submit If you are human, leave this field blank.