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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.
First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
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*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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 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. *
Parent or Guardian's Email Address
Email
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*
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 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. *
Parent or Guardian's Signature*
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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