Beckerman Recreation Center Membership & Locker Rental Cancellation Form

Request Form for current Beckerman Recreation Center members to cancel or hold their membership or locker.

Please note: the cancellation process can take 10-14 business days.

Please visit http://www.newhaven.edu/student-life/health-wellness/chargerrec/membership.php for our Membership Cancellation Policy.

Your Information

Member Name Member Name First Last

Member Email

I would like to:

I would like to: Cancel my membership (and locker, if applicable) Hold my membership (and locker, if applicable) Cancel just my locker rental

Membership Information

*Please note: 12-Month Upfront memberships will terminate on their expiration date. Members wishing to terminate their membership before their expiration date must receive written approval from the Director of Campus Recreation.

Membership Type

Membership Type Faculty/Staff Dependent Alumni New Haven Emeritus

Reason for Hold (check all that apply)

Reason for Hold (check all that apply) Medical Professional Leave Do not regularly use the facility Joined a different fitness/recreation facility Other

Begin Hold Date Begin Hold Date / MM / DD YYYY

The date you will no longer be using your membership. This is the earliest we will inactivate your account.

Reactivate Account Date Reactivate Account Date / MM / DD YYYY

The date you would like to return. This is the latest we will reactivate your account.

Membership Information

Membership Type

Membership Type Faculty/Staff Dependent Alumni New Haven Emeritus

Reason for Cancellation (check all that apply)

Reason for Cancellation (check all that apply) Do not regularly use the facility Joined a different fitness/recreation facility Facility does not meet my needs Other

Do you rent a locker?

Do you rent a locker? Yes No

Cancellation Effective Date

Cancellation Effective Date Immediately Other

If other please indicate the cancellation date below.

Cancellation Effective Date Cancellation Effective Date / MM / DD YYYY

Locker Cancellation Information

*Upon submittal of this form, all belongings must be removed from locker by the end of the day.

Locker Location

Locker Location Men's Locker Room Women's Locker Room

Locker Number

Reason for Locker Cancellation (check all that apply)

Reason for Locker Cancellation (check all that apply) Do not use locker Cancelled membership Other

Confirm Cancellation/Hold

Please draw your signature here to signal your intent to submit this cancellation. Upon submitting this form, you will receive an email with the information you submitted.

Date Date / MM / DD YYYY

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.