Membership Termination Request

MEMBERSHIP TERMINATION REQUEST
I am hereby requesting that the Membership and/or Team session(s) be terminated as indicated below.
Membership Account     Full Name
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Please enter the name of the Primary Membership Account Holder
Termination Type ?
Please select what service you wish to terminate.
Requested Termination Effective Date
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Please select what month your would like to terminate your membership.
I UNDERSTAND THAT:
•I will no longer be eligible for Membership Benefits.
•My termination is not effective until a Termination Request has been submitted and received by Inner Peaks, per my membership contract.
•Termination Request must be received by the 20th of the month prior to Termination Effective date.
•No refunds are made for Termination Requests received after the 20th of the month.
•Should I determine at a future date to resume my membership, I may be required to pay a membership join fee.
•If I elected the 6-Month Contract option and have not fulfilled my contract obligation, an Early Contract Termination Fee equal to the membership join fee becomes due and payable immediately. I authorize Inner Peaks to collect such fee utilizing my account information on record.

By providing my signature, I acknowledge and agree to the terms outlined herein.
Signature:
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Please acknowledge terms by entering your name. If membership account name and date of birth do not match, this Termination Request will be voided.
Accountholder Date of Birth (mm/dd/yyyy)
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Please enter primary account holder's date of birth.
Accountholder's Email
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Please enter primary account holder's email address for confirmation.
Contact Phone
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Please provide a contact phone number.
Reason for Termination
Type What you See
Type What you See

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