Healthworks Group Email Marketing -

Membership Freeze Request

First Name*

Last Name*

Email*

Phone*

Membership Agreement Number*

Freeze Request Type*

Personal Freeze - $6 bi-weekly / $13 monthly

Medical Freeze – No Fee

Maternity Freeze – No Fee

Military Freeze – No Fee

Religious Freeze - No Fee

Request Start Date*

Freeze requests must be submitted at least 5 days before the freeze is to start. A freeze will not be granted on a retroactive basis. If your membership is currently on freeze and you are requesting a change, please enter 2000-01-01 as the start date.

Request End Date*

Notes - Enter any additional information

Please select and end date compliant with the guidelines above.

I understand that my membership will automatically start billing again after the request and that refunds are not available. In addition, I will be responsible for any annual fees scheduled during this period, time on freeze does not count towards minimum number of payments and if I choose to cancel my membership, I will owe one more payment at normal membership dues.