Greater Waterbury YMCA Membership Termination Form
Member name: _____________________________________________________________ ID #: _____________________________
Membership type: ________________________________________ Language Preference: _________________________
Phone Number: __________________________________ Email: ______________________________________________________
Reason for termination: Moving Attach Membership Card here:
Medical
Lack of use
Financial
Other: ____________________________
Comments about the Greater Waterbury YMCA:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
• I understand there is a 30-day processing period for terminations. (Initial here): ________
• I understand that I will be drafted once more if my termination was submitted before the
14th of the month. (Initial here): _______
**A staff from the membership team will send you a confirmation email ONLY. That will let you know
about your final deduction and when the membership terminates.
For payroll deduction memberships (State of CT, City of Waterbury, Waterbury & St. Mary’s
Hospital):
• I understand that the Greater Waterbury YMCA is not responsible for any bank or payroll
department error. (Initial here): ___________
• I agree to contact my payroll department in order to guarantee that payroll deduction for
my membership fees is discontinued. (Initial here): ___________
Signature: _____________________________________________________ Date: ______________
Office Use Only:
Received by: __________ Date: __________ Processed by: __________ Date: __________
Notes: ______________________________________________________________________
136 West Main Street, Waterbury, CT 06762 phone: 203.754.9622 fax: 203.754.9095 www.waterburyymca.org
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