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2. Member Info
   Please fill out the request form if you wish to cancel your Liberty Community Center (LCC) Membership. To ensure the cancellation of your membership before your next payment, a 30 day notice is required for all monthly bank draft memberships.
3. Date*
   Date

   Date
5. First Name*
6. Last Name*
8. Address1*
10. City*
11. State*
12. Zip*
14. Phone Number*
15. Email*
19. Please select the type of membership you have*

    1. Adult
    2. Adult + 1
    3. Family
    4. Youth
    5. Senior
20. Please select the reason for the cancellation*

    (select all that apply)

    1. Personal schedule / personal reasons
    2. Did not use
    3. Gymnasium availability
    4. Pool availability
    5. Equipment availbility

    1. Moving
    2. Financial
    3. Another gym
    4. Home equipment
    5. *Other
22. *If other, please let us know
26. Rate Your Experience
    Under each category, please select the number that best describes your overall experience. If you did not utilize a particular area, please select NA.
28. Welcome Desk Staff*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely satisfiedNA- Did not use area
29. Additional comments
31. Facility Cleanliness & Staff*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely satisfiedNA- Did not use area
32. Additional comments
34. Wellness Center / Weight Room & Staff*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely SatisfiedNA- Did not use area
35. Additional comments
37. Swimming Pool Facilities & Staff*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely satisfiedNA- Did not use area
38. Additional comments
40. Child Watch & Staff*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely SatisfiedNA- Did not use area
41. Additional comments
43. Overall Experience*
    -- Select One --1- Dissatisfied2- Somewhat dissatisfied3- Somewhat satisfied4- Satisfied5- Completely satisfied
44. Additional comments
46. Receipt*

    1. Yes please
    2. No thank you
47. Thank You
    Your cancellation request will be submitted to the LCC administrator for processing. Please allow up to 48 hours for the request to be received. We would like to thank you for your business and hope to see you again in the future.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field