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Current Path : /hermes/sb_web/b2432/ymcamedia.ipower.com/forms/
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Current File : /hermes/sb_web/b2432/ymcamedia.ipower.com/forms/cancel_form.htm
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<table width="700" border="0" cellspacing="0" cellpadding="5" style="border: solid #000 1px;">
  <tr>
    <td><p align="center"><span class="style1">Cancellation</span><span class="style1"><br />
    </span>(Changes take 30 days to process)</p>
      <form id="form1" name="form1" method="post" action="http://www.ymcamedia.com/cancelform.php">
        Facility :
                <select name="s1" id="s1">
                  <option value="Bransby Outdoor">Bransby Outdoor</option>
                  <option value="Camp High Harbour">Camp High Harbour</option>
                  <option value="Centennial Place">Centennial Place</option>
                  <option value="Cherokee Outdoor">Cherokee Outdoor</option>
                  <option value="Covington">Covington</option>
                  <option value="Cowart/Ashford Dunwoody">Cowart/Ashford Dunwoody</option>
                  <option value="Decatur">Decatur</option>
                  <option value="East Lake">East Lake</option>
                  <option value="Fayette">Fayette</option>
                  <option value="Forsyth County">Forsyth County</option>
                  <option value="Fowler Peachtree Corners">Fowler Peachtree Corners</option>
                  <option value="Henry County">Henry County</option>
                  <option value="Isakson/Alpharetta">Isakson/Alpharetta</option>
                  <option value="Pruett Canton">Pruett Canton</option>
                  <option value="Sanders Buckhead">Sanders Buckhead</option>
                  <option value="South DeKalb">South DeKalb</option>
                  <option value="Summit Newnan">Summit Newnan</option>
                  <option value="Tull-Gwinnett">Tull-Gwinnett</option>
                  <option value="Villages at Carver">Villages at Carver</option>
                  <option value="Y Academies South DeKalb">Y Academies South DeKalb</option>
                  <option value="Young Southwest">Young Southwest</option>
                                </select>
<table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="350" nowrap="nowrap">Member Name :
              <input name="tf1" type="text" id="tf1" size="35" /></td>
            <td nowrap="nowrap">Member Type
              :
              <input name="tf2" type="text" id="tf2" size="10" /></td>
            <td colspan="2" nowrap="nowrap"><label>Member I.D. :
              <input name="tf3" type="text" id="tf3" size="11" />
            </label></td>
          </tr>
          <tr>
            <td nowrap="nowrap">Address
              :
              <input name="tf4" type="text" id="tf4" size="41" /></td>
            <td nowrap="nowrap">City
              :
              <input name="tf5" type="text" id="tf5" size="19" /></td>
            <td nowrap="nowrap">State :
              <input name="tf6" type="text" id="tf6" size="3" /></td>
            <td nowrap="nowrap">Zip
              :
              <input name="tf7" type="text" id="tf7" size="5" /></td>
          </tr>
          <tr>
            <td nowrap="nowrap">Phone :
              <input name="tf8" type="text" id="tf8" size="43" /></td>
            <td nowrap="nowrap">New Address?&nbsp;&nbsp;&nbsp;Yes
              <input name="rb1" type="radio" value="yes" />
              &nbsp;&nbsp;No
              <input name="rb1" type="radio" value="no" /></td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
        </table>
        <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td><hr width="90%" /></td>
          </tr>
        </table>
        <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td colspan="3"><label>Payment Type :
              <select name="s2" id="s2">
                    <option value="Draft 1st">Draft 1st</option>
                    <option value="Draft 15th">Draft 15th</option>
                    <option value="Annual">Annual</option>
                    <option value="Semi-Annual">Semi-Annual</option>
              </select>
            </label></td>
          </tr>
          <tr>
            <td><label>Refund Due:</label></td>
            <td>Yes
              <input name="rb2" type="radio" value="yes" />
                <label>&nbsp;&nbsp;&nbsp;&nbsp;No
                  <input name="rb2" type="radio" value="no" />
              </label></td>
            <td>&nbsp;</td>
          </tr>
          <tr>
            <td nowrap="nowrap">Is anyone in your family enrolled in YMCA programs?&nbsp;<label></label></td>
            <td nowrap="nowrap"><label>Yes
                <input name="rb3" type="radio" value="yes" />
            </label>
              <label>&nbsp;&nbsp;&nbsp;&nbsp;No
              <input name="rb3" type="radio" value="no" />
              </label></td>
            <td nowrap="nowrap"><label></label>
                <label></label></td>
          </tr>
          <tr>
            <td nowrap="nowrap"><label></label></td>
            <td nowrap="nowrap">Last Draft Date :
            <input name="tf9" type="text" id="tf9" size="5" /></td>
            <td nowrap="nowrap">Last Day to Use Facility :
              <input name="tf10" type="text" id="tf10" size="5" /></td>
          </tr>
        </table>
        <div align="center">
          <table width="700" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td><hr width="90%" /></td>
            </tr>
          </table>
          <span class="style3">Reason for Cancellation</span><br />
          (You must select one) 
          <table width="700" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td><hr width="90%" /></td>
            </tr>
          </table>
        </div>
        <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td><label>
              <input name="cb1" type="checkbox" id="cb1" value="Facility Cleanliness" />
Facility Cleanliness</label></td>
            <td><input name="cb2" type="checkbox" id="cb2" value="Facility Too Crowded" />
Facility Too Crowded</td>
            <td><input name="cb3" type="checkbox" id="cb3" value="Relocation" />
Relocation</td>
            <td><input name="cb4" type="checkbox" id="cb4" value="Pregnancy" />
Pregnancy</td>
          </tr>
          <tr>
            <td><input name="cb5" type="checkbox" id="cb5" value="Program Quality" />
              Program Quality</td>
            <td><label>
              <input name="cb6" type="checkbox" id="cb6" value="Joined Another Facility" />
              Joined Another Facility</label></td>
            <td><input name="cb7" type="checkbox" id="cb7" value="Transfer to Another YMCA" />
              Transfer to Another YMCA</td>
            <td><input name="cb8" type="checkbox" id="cb8" value="Financial Hardship" />
              Financial Hardship</td>
          </tr>
          <tr>
            <td><label>
              <input name="cb9" type="checkbox" id="cb9" value="Location of Facility " />
              Location of Facility</label>
                <label> </label></td>
            <td><label>
              <input name="cb10" type="checkbox" id="cb10" value="Lack of Use" />
              Lack of Use</label></td>
            <td><label>
              <input name="cb11" type="checkbox" id="cb11" value="Medical" />
              Medical</label></td>
            <td>&nbsp;</td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
        </table>
        <p>
          <input name="Submit" type="submit" />
          &nbsp;
          <label>
          <input type="reset" name="Submit2" value="Reset" />
          </label>
        </p>
      </form>
    <p></p></td>
  </tr>
</table>
<p align="center">&nbsp;</p>
Creat By MiNi SheLL
Email: devilkiller@gmail.com