Membership Category Change Form

Change Your New Canaan YMCA Monthly Membership Category

"*" indicates required fields

This form is for monthly membership category changes only. If you wish to upgrade your annual membership, please contact Laura Ryan, Member Relations Administrator, at 203-920-1629 or [email protected].

Member Name*

First Last

Date of Birth*

Phone*

Email*

Current Membership Category*

Please select your current membership category.

New Membership Category*

Please select your new membership category.

Monthly Membership Fee: The primary customer gives permission to withdraw the monthly membership fee from their account. If a primary customer wishes to cancel/suspend this membership for any reason, please complete the Membership Cancellation/Suspension form on the Y’s website one week prior to draft date.

Please specify how many active members will remain on your account.*

If you are not adding additional members to your account, please select Non-Applicable.

Please list active members.*

Please use the (+) to add additional members.

First Name

Last Name

Gender

Date of Birth

I acknowledge that my membership category and associated fees will be changed as requested on this form.*

Date*

CAPTCHA