First Name *

Last Name *

Email *

Membership Number *

Membership Freeze Request Date *

Membership Freeze Date End (must be less than 6 months from today) *

Freeze Reason *

If you select Medical, we will respond to you asking for a medical note. If you do not provide documentation you may be charged $10 per month.

By filling out this form, you are consenting to the use this submission in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By continuing, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

I Agree - (A membership freeze fee of $10 + HST a month will apply if you are freezing your membership for non-medical reasons or if you do not provide a medical note.)