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Request for Monthly Pass Cancellation Form

2. Terms and Conditions of Cancellation Policy*

   - Evergreen Park & Recreation District requires a 30-day notice for all monthly facility passes to be cancelled; meaning an additional payment will be taken if this request is submitted after the first of the month.
   - If you have not met the minimum requirement of 3 full months of payments, additional payments will be taken to equal 3 months of payment in full, prior to the cancellation of the pass.
   - Any past due amounts will be collected at the time of the final payment.

   1. I have read, understand and agree to the terms and conditions of the cancellation policy listed above.
4. Which type of monthly pass are you cancelling?*
   -- Select One --YouthAdultMilitary/SeniorCouples - AdultCouples - Military/SeniorFamily of FourFamily of Four - Military

6. Name of person completing cancellation form:*

7. List of all other additional pass holders (if applicable):

9. Email Address*

10. Primary Phone Number*

12. Please read and acknowledge the following statements:*

    1. I acknowledge I may be charged the next monthly payment, as it is required to give 30 days notice of cancellation.
    2. I understand by cancelling my monthly facility pass, I and all other pass holders will be subject to fill out a new facility pass agreement in person at either Buchanan Park or Wulf Rec Center.
14. Reason for Cancellation*

18. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

    1. I agree
20. Signature (First, M. Last)*

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

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