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BRUNO DIAS BRAZILIAN JIU JITSU ACADEMY

1536 SUNRISE PLAZA DR SUITE 104

CLERMONT, FL 34714

(352) 432-3111

www.bddjjacademy.com


THIS IS NOT A TERMINATION REQUEST

As stated in your membership agreement, you have the option to put your automatically recurring monthly membership on hold for any reason.

1. As stated in our membership agreement, you have the option to put your automatically recurring monthly membership on hold for any reason. We understand things come up and we’d like to do what we can to help.

2. Membership hold requests must be submitted no less than 5 business days before your forthcoming scheduled renewal date. Membership hold requests received later cannot be processed until after the forthcoming scheduled renewal payment. All membership payments are non-refundable. Membership hold requests are limited to one time per calendar year in 30-day increments for up to three consecutive 30-day periods (30, 60, or 90 days).

3. Upon expiration of the hold period that you select below, your account will automatically reactivate and regular membership payments will resume. If you chose to cancel your membership during the hold period, the standard 30-day notice requirement stated in your membership agreement is applicable. If you choose to reactivate your membership after it is canceled, membership rates in effect at the time of reactivation will be applicable (membership rates are subject to change).

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
I understand that hold requests must be submitted no less than 5 business days before my forthcoming scheduled non-refundable renewal payment.
Click to customize drop-down*
I understand that my non-refundable renewal payment will be processed if this request is submitted less than 5 business days before my renewal date.
Click to customize drop-down*
I understand that if I cancel my membership during the hold period, the 30-day notice required by my membership agreement is still applicable.
Click to customize drop-down*
I understand that my membership and non-refundable payments will resume automatically upon expiration of the hold period that I selected above.
Click to customize drop-down*
I acknowledge and accept the terms for hold.
Click to customize drop-down*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Hold start date:

Hold start date: *
Membership hold duration:*

Reason for requesting Membership hold: *
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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