Duke Center For Living at Fearrington

Membership Cancellation

Membership Vacation Freeze Request

"*" indicates required fields

Print clearly. Check and complete the relevant section. Return completed form to DCFL Member Services Desk.

PLEASE NOTE:

Requests must be received 30 days in advance of the requested start date and are subject to the Member Services Manager’s approval.

1. Complete Member Information.

Member(s) Name*

Todays Date*

Cell #*

Email

Freeze may be granted for a minimum of one month and a maximum of 6 months, in full month increments only.
Freeze does not have to begin on the first of the month.
Cost of Freeze = $12 per month per member
Early return must have taken at least 30 days freeze
Members may not use services that are on a frozen account without incurring additional charges.

Start Date*

End Date*

Total # of Months:*

Total Cost: $__*

Reason

Membership Medical Freeze Request

"*" indicates required fields

Print clearly. Check and complete the relevant section. Return completed form to DCFL Member Services Desk.

PLEASE NOTE:

Requests must be received 30 days in advance of the requested start date and are subject to the Member Services Manager’s approval.

1. Complete Member Information.

Member(s) Name*

Todays Date*

Cell #*

Email*

Freeze may be granted for a minimum of one month and a maximum of 6 months, in full monthly increments only.
Freeze does not have to begin on the first of the month.
A physician’s note clearly stating the reason for the request must be either attached or faxed to DCFL at 919-545-2687.
Physician’s Note must be received to implement the freeze.
There is no charge for the freeze. If a note is not received you will be charged $12 per month.

Start Date*

End Date*

Total # of Months:*

Total Cost: $__*

Reason

Physician Note Checkbox

Physician note is attached.

Physician will fax note to DCFL {919-545-2687).

Physician Note

Max. file size: 50 MB.