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Membership Cancellation

Membership Vacation Freeze Request

"*" indicates required fields

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

VACATION FREEZE

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

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Membership Medical Freeze Request

"*" indicates required fields

PLEASE NOTE:

Physician’s note with the start and end date must be attached to implement the freeze. Requests without a note attached, and that do not follow the date range parameters will NOT be implemented.

1. Complete Member Information.

Member(s) Name*

Todays Date*

Cell #*

Email*

MEDICAL FREEZE

Physician’s note must be received to implement the freeze clearly stating the reason for the freeze with a START AND END date.
The freeze can start on any day of the month.
If you wish to return sooner than the physician’s recommendation, they will need to submit another note clearing you for exercise.
There is no charge for the freeze. If a note is not received, $12 will be charged per month.
Upload the note here, fax to: 919-545-2687, drop off at DCFL front desk, or email to: [email protected].

Start Date*

End Date*

Total # of Months:*

Total Cost: $__*

Reason

Physician Note*

Max. file size: 50 MB.

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Hours

VACATION FREEZE

Membership Medical Freeze Request

MEDICAL FREEZE