Form

Program Cancellation/Change Request

First name*

Last name*

Birthday (XX/XX/XXXX)*

Street address*

City*

State*

Zip Code*

Email*

Phone number*

Branch Program Location*

Program Participant Information

Program Participant First Name*

Program Participant Last Name*

Program Name*

Program Date/Time*

Do you have other programs that you would like to cancel/change?*

Yes

CHOOSE ONE OF THESE OPTIONS*

CREDIT: If any monies are due me, I would like a credit left on my YMCA account. This credit will remain on my account until I choose to use it and may be applied to YMCA programs or membership dues.

REFUND: If any monies are due me, I would like a refund. I understand if my original payment was made by cash, check or EFT draft, this refund will be in the form of a check mailed to my address listed above and may take up to three weeks to receive. Original payments made by credit card are returned to the same card and may take up to a month to see on my statement (this varies by credit card company).

TRANSFER: I would like to transfer any monies due to me to the following program(s):

Comments

I understand that this form is a REQUEST to cancel/change my program and that all requests will be evaluated against the stated cancellation policies for each program. Cancellation policies for YMCA programs can be found at ymcacharlotte.org.*

By checking this box, I agree to the information listed above and acknowledge that the information I have provided is correct. *