Please complete the below form to request to cancel your membership. Cancellation is subject to receipt and acknowledgement by RUSH Copley Healthplex. Name First Last Names of all members to be cancelled (include self if applicable) Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Address Reason for Cancellation Relocation Medical Financial Usage Service Availability Other If other, please explain. 30-day notice This application serves as my 30-day written notification of cancellation in accordance with RUSH Copley Healthplex Contract Terms. Membership will terminate 30 days from today's date (unless bound by a current contract). Final EFT will include any and all prorate dues, house charges, and unpaid charges prior to the cancellation date of membership. Past due balance I acknowledge that cancellation cannot occur with past due balances. Any outstanding charges must be paid prior to cancellation or charges will continue to accrue. Contract I understand if my membership is currently in a contract, I may only withdraw from the contract for relocation of more than 25 miles of RUSH Copley Healthplex with proof of new address or documented medical reason provided by a physician. Cancellation of a contract will not be processed without providing additional documentation. Leave this field blank
Please complete the below form to request to cancel your membership. Cancellation is subject to receipt and acknowledgement by RUSH Copley Healthplex. Name First Last Names of all members to be cancelled (include self if applicable) Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Address Reason for Cancellation Relocation Medical Financial Usage Service Availability Other If other, please explain. 30-day notice This application serves as my 30-day written notification of cancellation in accordance with RUSH Copley Healthplex Contract Terms. Membership will terminate 30 days from today's date (unless bound by a current contract). Final EFT will include any and all prorate dues, house charges, and unpaid charges prior to the cancellation date of membership. Past due balance I acknowledge that cancellation cannot occur with past due balances. Any outstanding charges must be paid prior to cancellation or charges will continue to accrue. Contract I understand if my membership is currently in a contract, I may only withdraw from the contract for relocation of more than 25 miles of RUSH Copley Healthplex with proof of new address or documented medical reason provided by a physician. Cancellation of a contract will not be processed without providing additional documentation. Leave this field blank
