FREEZE REQUEST FORM

Name *

First Name

Last Name

Phone

(###)

###

####

Preferred Start Date

MM

DD

YYYY

Non-Medical/Voluntary Freeze: By entering Yes (“Terms and Conditions”), I understand that a non-medical freeze is effective upon the next billing date for a maximum three (3) months per twelve month calendar period. I understand that there is an administration fee of $10 per month, in lieu of, my monthly dues membership charge. To request a freeze, I must (1) submit this form to QAWIYA at least 14 days in advance of the requested freeze date and (2) be current on all dues, fees, and other charges on my account. *

YES

N/A

Medical Freeze: By entering Yes (“Terms and Conditions”), I am obligated to complete this form and provide QAWIYA with a Physician’s note stating a freeze of membership for medical purposes is necessary for up to three (3) months. Failure to do so will result in an automatic reinstatement of my monthly membership dues. *

YES

N/A

Terms and conditions: By entering Yes (“Terms and Conditions”) and submitting this form, I acknowledge that the above information is accurate and correct. Any misrepresentations with the current information are the sole responsibility of the undersigned. I understand that that freezing of my membership will be executed as per the terms and time frame outlined in my membership agreement. I authorize QAWIYA to charge my credit card that is on record with QAWIYA and collect any outstanding balances that remain on my account upon the successful freezing of my membership. Furthermore, I understand that I cannot cancel my membership while frozen. *

YES