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Membership Hold Request
Memberships may only be placed on hold for 2-4 consecutive months within a 12 month period. Held memberships will be charged $10 per month with the sum of the entire hold period being paid upon submission of this hold request. 
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Today's Date:  *
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Primary member name:  *
Primary member's date of birth:  *
Phone number:  *
Type of Membership being put on hold:  *
Do you &/or another individual on the account have a 24hr Access FOB? *
Do you &/or another individual on the account rent a locker? If so, what is the locker # and where is it located? *

By signing below, I acknowledge and agree to the following:

*This form serves as the YMCA’s official Member Hold Request. 
*To change payment information, requests must be submitted by the 24th of the prior month to avoid the next draft. 
*I am responsible for checking my bank statements to confirm that drafts have stopped. 
*The YMCA does not issue refunds for membership dues charged after the hold effective date.
*

By signing below, I acknowledge and agree to the following:

*My Southeastern Indiana YMCA membership will be placed on hold. 
*  Automatic bank and debit/credit drafts will resume on the 1st of the month when the hold ends. 
*  During the hold, I will not have access to member benefits, including discounted rates, guest passes, Nationwide Membership, or reciprocity privileges. 
*  Fob access will be deactivated for the duration of the hold.
*I am responsible for the difference between member and non-member rates for any programs I registered for that occur during or after the hold start date. 
*Hold fees are non-refundable.
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Months Hold Requested:  *
Required
Total Months on Hold:  *
Total Due Today:  *
Reason for Hold:  *
Please sign and date below to authorize the Southeastern Indiana YMCA to place your membership on hold. The amount indicated above will be charged, and payments will automatically resume on the 1st of the month in which the hold period ends. *
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