Loyalty martial arts cancellation form request

Facility

Account holder / Bill payer Full name

Address

Mobile

DOB

Membership package type

You can find the membership package type on the email you have received when sign up!

If the Account holder / Bill payer also a student YesNo

Student name

Has the account holder / bill payers included a student under 18 years old in the same account? YesNo

Student name

DOB

Package type

Please state the reason for cancellation

If the cancellation is for medical reasons, please attach support documents for perusal.

Cancellation terms and conditions

I understand that if i have signed up for a membership package that requires a 4 week notice cancellation period an email will be sent replying to this cancellation form request with the reminder debit date incurred in that 4 week notice period. payments must be honoured prior to cancellation of membership taking place.

I understand that if i have signed up for the NO LOCK-IN membership package cancellation of membership payments may take 48 to 72 hours after this cancellation request form has been received. An email will be sent from your facility confirming cancellation.

I understand and agree with the above cancellation terms & conditions.

Date

Signature