Membership Freeze Request

Member Name(Required)

First Last

Email(Required)

Freeze Type(Required)

Why do you want to freeze your membership?

Freeze Start Date(Required)

Number of Months to Freeze(Required)

YOU CAN FREEZE YOUR MEMBERSHIP FOR UP TO THREE (3) MONTHS AT NO CHARGE WITH A MEDICAL NOTE.

Medical Note(Required)

Max. file size: 128 MB.

Medical Note Signed and Stamped From Doctor Required

YOU CAN FREEZE YOUR MEMBERSHIP FOR NON-MEDICAL REASONS FOR $10 per month.

Number of Months to Freeze ($10p/m)(Required)

There is a charge of $10 Per Month to Freeze a membership for a non-medical Reason.

Agreement(Required)

I confirm that I understand that a freeze puts my membership on hold temporarily and extends the end dated of my membership based on the period of time my membership is frozen. You also agree that you are responsible for the monthly freeze rate and the subsequent monthly fees after the freeze ends.

I agree to the terms

Signature