Membership Change or Hold Request Form
Members, to make a change in your membership or to place your membership on hold, please fill out this form. Changes or holds will not be effective until Lorraine, Member Account Representative, contacts you.
Questions? Email Lorraine at LorraineT@wearepcc.com
Primary Account Holder's Name
Contact Info Update
Electronic Funds Transfer (add/change/update)
Checking Account (Must provide a voided check to Lorraine.)
Account Number (for Visa or MC)
Expiration Date (for Visa or MC)
- Add or Delete for Full or Swim/Fit memberships ONLY.
- Additions are effective immediately and deletions are effective the next billing cycle.
(If adding adult add-on, please complete New Application Form, which will be emailed to you by Lorraine. Adult Add-On membership is not effective until that form is filled out.)
- Dependents are an additional $8 each per month.
- Dependents over 17 must sign the Release & Waiver form, which will be emailed to you by Lorraine. Membership for added dependent is not effective until that form is filled out.
- Dependents must be as defined by the IRS and are: a) Ages 2-25, b) Disabled or Dependent Adults (parents) living with you, or c) Live-in Nanny.
ADD OR DELETE DEPENDENT #1
Add Dependent #1
Delete Dependent #1
Dependent #1 Full Name
Dependent #1 Birthdate (MM/DD/YY) & Age
Dependent #1 Relationship to You
ADD OR DELETE DEPENDENT #2
Add Dependent #2
Delete Dependent #2
Dependent #2 Full Name
Dependent #2 Birthdate (MM/DD/YY) & Age
Dependent #2 Relationship to You
CHANGE IN MEMBERSHIP TYPE:
Full to Swim/Fit,
Swim/Fit to Full,
or Swim/Fit to Masters only.
Masters Only to Full or Swim/Fit is an upgrade and REQUIRES a New Membership Application, which will be emailed to you by Lorraine.
NOTE: Upgrades MAY require the payment of additional dues and/or registration fees. Full to Swim/Fit will be effective next billing cycle and Swim/Fit to Full will be changed as of the effective date below. Full or Swim/Fit memberships changing to Masters Only requires a 30 day cancellation notice.
Current Membership Type:
Change Membership Type To:
When would you like membership change to take effect?
Add or Remove Masters Swimming? (Write Add, Delete or N/A)
AUTHORIZING SIGNATURE - By entering my full name below, I authorize all the above changes. These changes will remain in effect until I have given Peninsula Community Center written notice of its termination at least thirty (30) days prior to the effective date of termination.
MEMBERSHIP HOLD - REQUEST
Hold Policy: Members may apply for a hold on their membership under the following conditions:
1) Extended illness or injury,
2) Extreme financial hardship (i.e. job loss, pay cut, sudden significant drop in income), or
3) Extended vacancy/travel.
Note: General lack of use is NOT an acceptable condition for hold. All HOLDS must be for a MINIMUM of 3 months and a MAXIMUM of 12 months and must be approved by management before taking effect. There may be a $30 monthly fee while the membership is on hold. You will receive confirmation of your request by mail or email which will include whether this fee is payable or not.
My full name below authorizes my membership to be placed ON HOLD (write N/A) if you want to remove from hold, and see option for hold removal below:
Number of months for hold (minimum of 3 months and maximum of 12):
Reason for hold:
My full name below authorizes my membership to be taken OFF HOLD (or write N/A):
My full name below authorizes my request to resign my membership (or write N/A).
Do Not Fill This Out