Person Completing Form *

Phone *

Email *

Family Last Name *

Child(ren) Name(s) *

Current Membership Level *

Preschool Age

School Age

Other

Date to Begin Freeze *

Date to Reinstate (must be within 60 day of the Freeze Date) *

I understand the freeze policy *

Yes

Why is there a FREEZE Option? How does it help?

I understand that the FREEZE OPTION is a customer courtesy and is provided to me so that I may avoid paying additional enrollment fees SO LONG AS I FOLLOW AND ADHERE TO THE FREEZE PROGRAM I HAVE AGREED TO, IN ACCORDANCE WITH THE LANGUAGE IN THIS DOCUMENT.

I understand the freeze benefit to me *

Yes

Will I get a refund if I change my mind after the FREEZE automatically ends and do nothing?

I understand that there will be NO REFUNDS FOR MEMBERSHIP CHARGES THAT OCCUR ONCE MY ACCOUNT HAS BECOME UNFROZEN BASED ON THE INFORMATION I HAVE PROVIDED. Furthermore, that it is MY PERSONAL RESPONSIBILITY TO CONTACT ALPHA OMEGA GYMNASTICS & DANCE DURING THE TIME PERIOD THAT THERE IS A FREEZE HOLD ON MY ACCOUNT if I choose not to re-enroll for classes in order to avoid automatic start of tuition charges for the dates I have designated above.

I understand my responsibility to cancel to avoid mom-refundable charges when freeze ends *

Yes

Are you satisfied with the services you received from Alpha Omega? *

Yes

Would you recommend our program to a friend? *

Yes

Any additional comments or suggestions you would like to give us?

I request a suspension of my child’s membership for 2 months (a “freeze”). If today is the 9th of the month or earlier, the freeze will go into effect on the 1st day of next month. If today is after the 9th of the month, the freeze will go into effect on the 1st day of the month after next. I understand and agree my child’s membership will resume on the 1st day of the month after the freeze expires. My monthly charges will resume in the month the freeze expires with a charge on the 15th of each month for the following month. I also understand and agree that I am responsible for re-enrolling my child(ren) in classes. (Here is an example of how this freeze works, if a member requests a freeze on May 9th no drafts/charges will occur in May and June and the child’s gym membership will be suspended during the months of June and July. On July 15th the account will be drafted/charged for August’s payment obligation. The member will need to contact the gym to enroll for classes in August.)

Freeze Request Signature *

Clear

I also understand and agree that I am responsible for increase of tuition that might have occurred during my absence for my child(ren), should I choose to return to classes.

Tuition Increase Acknowledgement Signature *

Clear

Should I dispute a charge through my financial institution this will constitute a breach of contract possibly resulting in, but not limited to, penalties, additional fees, collection, legal action, and/or termination of any and/or all current and past agreements.

Dispute Signature *

Clear