Membership Freeze Form

Fitness Center
MEMBERSHIP FREEZE FORM
Form Type
MEMBERSHIP FREEZE POLICY: PIF or EFT Memberships may be frozen, at anytime and for any reason, by completing the YVY Fitness Center Membership Freeze Form, available at the Fitness Center, or by written notice, via certified mail, return receipt requested to YVY Fitness Center, 1312 38th Street, SUITE 515, Brooklyn, New York 11218, by the 1st of the month prior to the membership freeze date.

A Member shall have the right to freeze a membership once per twelve month period for one (1) two (2) or three (3) consecutive months. A Member must be in good standing and current with membership dues at the time of request. During the membership freeze period no dues will be collected. Memberships will be reactivated automatically at the end of your freeze period. PIF Memberships will be extended automatically by the amount of time frozen & EFT membership dues charges will automatically resume. A freeze request cannot be retroactive.

Medical Disability Freeze: You must complete a Membership Freeze form as well as submit written verification from your physician stating that your medical disability will prevent you from using the Fitness Center. The term for a medical freeze is two (2), three (3), four (4), five (5) or six (6) consecutive months within a twelve (12) month period. YVY Fitness Center reserves the right at its sole discretion, to require medical clearance prior to allowing member to return from a medical disability freeze or to deny re-entry for any member may be suspected (for any reason) of having a medical condition deemed by YVY Fitness Center to be detrimental to the safety, health or wellbeing to the his/herself or any other Member or Guest. A freeze request cannot be retroactive.
Name*
Address*

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Requested Membership Freeze Date*

MonthDayYear
Date
Requested Membership Resume Date*

MonthDayYear
Date
Member Signature*

Clear
Member Signature Date

MonthDayYear
Date
Member under 18 signatures of Parent or Guardian

Clear
Member under 18 signatures of Parent or Guardian Date

MonthDayYear
Date
Check one*

GENERAL FREEZEMEDICAL DISABILITY FREEZE - DOCTORS NOTE ATTACHED
*Please note: Although the Fitness Center will take into account the requested membership freeze date, the effective membership freeze date will be determined by management in accordance with the policies listed above.
For Office Use Only
Member#
Effective Membership Freeze Date

MonthDayYear
Date
Effective Membership Resume Date

MonthDayYear
Date
Membership Extended (Paid in Full Members Only) From:

MonthDayYear
Date
Till:

MonthDayYear
Date
Staff Signature

Clear
Date

MonthDayYear
Date
Yeled V Yalda your child, our world

1312 38th Street Brooklyn, NY 11218 - 718.686.3700 W .yeled.org
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Fitness Center

MEMBERSHIP FREEZE FORM