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Request to Terminate Auto Pay Agreement

2. First Name*

3. Last Name*

4. Today's Date*
   Today's Date

6. Address*

8. City*

9. State*

10. Zip*

12. Phone*

13. Email*

15. Membership Plan*
    -- Select One --PlatinumSilverBronze PlusBronzeCorporate

16. Membership Type*
    -- Select One --IndividualFamily

18. Reason for canceling membership

    1. Change of Employment
    2. Do Not Use Membership
    3. Family Emergency
    4. Joined other Facility
    5. Medical
    6. Moved
    7. Seasonal Membership
    8. Too Busy
    9. Too Expensive/Financial Burden
    10. Dissatisfied (please comment below)
    11. Other (please comment below)

19. Will you rejoin the DRC?

    1. Yes
    2. No

21. Please rate each category on a scale of 1-5, with a 5 being excellent.

23. Cleanliness of Facility

24. Staff Friendliness

25. Hours of Operation

26. Amount of Equipment

28. Communication to Members

29. Value for the Price

30. Staff Knowledge

31. What would you change about your DRC experience?

33. Original agreement form

    1. Yes
    2. No

34. Original Receipt Number

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field