Please complete the below form to request to freeze your membership. Request is subject to receipt and acknowledgement by RUSH Copley Healthplex. Names of all members to be frozen 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 Freeze Travel Medical (documentation may be required) Seasonal Other Do you have a locker? Yes No If you have a locker, would you like to keep it? Locker charges will apply while on freeze. Yes No Your freeze request will be effective the first day of the following month after the request has been submitted. Freeze Start Date Freeze Start Date: Year Year20232024202520262027202820292030203120322033 Freeze Start Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Reactivate Membership On Reactivate Membership On: Year Year20232024202520262027202820292030203120322033 Reactivate Membership On: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Freeze Start Date Freeze End Date Members may only freeze up to 6 months in a calendar year. Nominal Fee Acknowledgement I acknowledge that by freezing my membership I am agreeing to pay a nominal fee of $10 per adult and $5 per child each month in place of regular dues. My membership will automatically reactivate on the date indicated on this form. Cancellation Agreement I understand cancellation may not occur while on freeze. To cancel, membership will be reinstated for one month to fulfill the required 30 day notice. Contract Acknowledgement I understand if my membership is currently in a contract, my contractual term will be extended by the length of the freeze. Membership may be placed on freeze for a minimum of one month and a maximum of six consecutive or non-consecutive months per calendar year. Leave this field blank
Please complete the below form to request to freeze your membership. Request is subject to receipt and acknowledgement by RUSH Copley Healthplex. Names of all members to be frozen 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 Freeze Travel Medical (documentation may be required) Seasonal Other Do you have a locker? Yes No If you have a locker, would you like to keep it? Locker charges will apply while on freeze. Yes No Your freeze request will be effective the first day of the following month after the request has been submitted. Freeze Start Date Freeze Start Date: Year Year20232024202520262027202820292030203120322033 Freeze Start Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Reactivate Membership On Reactivate Membership On: Year Year20232024202520262027202820292030203120322033 Reactivate Membership On: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Freeze Start Date Freeze End Date Members may only freeze up to 6 months in a calendar year. Nominal Fee Acknowledgement I acknowledge that by freezing my membership I am agreeing to pay a nominal fee of $10 per adult and $5 per child each month in place of regular dues. My membership will automatically reactivate on the date indicated on this form. Cancellation Agreement I understand cancellation may not occur while on freeze. To cancel, membership will be reinstated for one month to fulfill the required 30 day notice. Contract Acknowledgement I understand if my membership is currently in a contract, my contractual term will be extended by the length of the freeze. Membership may be placed on freeze for a minimum of one month and a maximum of six consecutive or non-consecutive months per calendar year. Leave this field blank
