ORCAS ATHLETICS, BRS, Ltd.
P.O. Box 786 Eastsound, WA 98245
Office: 360.376.6361 Fax: 360.376.6365 www.orcasspaandathletics.com
MEMBERSHIP FREEZE REQUEST

I am requesting a freeze of my membership.

I understand that Orcas Athletics policy makes allowance for membership freezes only under the following circumstances. I have indicated which one applies to me by checking below. I understand that I may be asked to provide verification of this.

_____ I am a part time resident who is gone up to 6 months out of the year.
_____ I have a medical condition that temporarily prevents me from exercising.
_____ I am experiencing some other extenuating circumstance and have received a special freeze approval by Orcas Athletics Management. (See management notes below.)

By initialing below I acknowledge my understanding of the following freeze policy.

_____ To qualify for a membership freeze I must be signed up for automatic payment through a checking account or credit card.
_____ A monthly fee of $17.95 will be automatically charged to my account during the freeze period.
_____ A membership can only be placed on freeze for a maximum of 6 months.
_____ Freezing a membership also freezes the contract term. My membership renewal date will be adjusted to reflect the addition of the length of my membership freeze.
_____ Freeze and unfreeze dates must be prior to the 15th of any given month.

Signing below indicates my understanding of this policy and my intention to cooperate with it.

I request a freeze of my membership effective: __________________________________

I request that my membership be reactivated effective: ___________________________

___________________________________________________ ________________________
Member Signature Date Signed

________________________________________________________________________
Print Name Email Address

For Office Use Only

Received By__________________________ Date Received _______________________

Extenuating Circumstances, Owner/Manager OK:
Notes: