2. Complete this form to make status changes to your membership. Please note that cancelations made on the last day of the month will not be processed until AFTER the next credit card draft takes place (typically on the 1st of each month).
4. Member Name (Primary Account Holder):*
5. Date:*
   Date:
7. Phone Number:*
8. Address:*
10. Based on your experience as a member, how likely would you be to recommend Green Ridge to a friend?*

    1. 0 (not likely at all)
    2. 1
    3. 2
    4. 3

    1. 4
    2. 5 (neutral)
    3. 6
    4. 7

    1. 8
    2. 9
    3. 10 (extremely likely)
12. Why have you decided to leave Green Ridge? (check all that apply)*

    1. Coronavirus (COVID-19)
    2. Facility too crowded
    3. Facility not clean
    4. Hours of operation
    5. Loss of motivation

    1. Medical reasons
    2. Monetary problems
    3. Quality of programs poor
    4. Relocation / moving

    1. Staff members not helpful
    2. Switching to another facility
    3. NONE OF THESE
    4. OTHER
14. If OTHER, please provide provide why you decided to leave Green Ridge.
16. Please provide further details about your decision to change your membership status:
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field