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2. Membership Cancellation Request
   Please note Membership Cancellation Request MUST be received at least 10 days prior to your EFT draft date.
4. Name as it appears on Membership*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Please cancel my membership to the Vandalia Recreation Center for the following reason(s): *

    1. Moving
    2. Not Used Enough
    3. Illness / Medical Reason
    4. Other
17. Please provide your new address.
19. Please specify reason. You may be required to provide medical documentation.
21. Please specify the reason you are cancelling your VRC Membership.
23. Authorization
    By signing your electronic signature you understand that by cancelling in any month OTHER than the month you joined a $50.00 cancellation fee may apply. Cancellation fees can be waived if written documentation of injury, death, relocation or other life altering reason is submitted and approved by the Administrative Coordinator. The cancellation fee will be your last EFT withdrawal unless you pay this separate, prior to the withdrawal date.
25. Electronic Signature*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field