Membership Freeze Form

The EDGE

Essex/South Burlington - Vermont

Membership Freeze Form

Please complete this form to request a freeze on your EDGE membership. NOTE: There is a ONE MONTH minimum for membership freezes. Freezes cannot be less than one month.

I understand that it is my responsibility to contact the EDGE within 30 days if I experience any billing error.
I understand that payments already made are not refundable.
I understand that this freeze is not considered complete until a confirmation email is received from an EDGE Membership Director.
Membership on SimplePay, monthly payments – freezes must be done by the calendar month.
Memberships that are limited may not be eligible for freeze.

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

Continue

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*

First Participant's Age Acknowledgment*

First Participant's Date of Birth*

I certify that I am 18 years of age or older

First Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested Start Date (NOTE: SimplePay Memberships must be submitted for freeze by 1:00pm on the last day of the month to avoid billing on the first day of the next month) . Membership dues are non-refundable after this time due to processing fees incurred. *

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

First Participant's Signature*

Type Signature

Draw Signature

Click to Sign

Second Participant's Name

First Name*

Middle Name

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Third Participant's Name

First Name*

Middle Name

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Fourth Participant's Name

First Name*

Middle Name

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Fifth Participant's Name

First Name*

Middle Name

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Sixth Participant's Name

First Name*

Middle Name

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Seventh Participant's Name

First Name*

Middle Name

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Eighth Participant's Name

First Name*

Middle Name

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Ninth Participant's Name

First Name*

Middle Name

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Tenth Participant's Name

First Name*

Middle Name

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Parent or Guardian's Email Address

Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*

Parent or Guardian's Age Acknowledgment*

Parent or Guardian's Date of Birth*

I certify that I am 18 years of age or older

Parent or Guardian's Information

Any other participants connected to your membership you wish to freeze.

Reason For Freeze

Seasonal

Travel

Medical

Other

Requested End Date Your membership will resume automatically on this date. To extend your freeze, simply complete this form again. *

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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Agree To This Document