"*" indicates required fields Date* MM slash DD slash YYYY Primary Member Name* Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Action to be Taken* Deactivate (may not be used to cancel membership; please fill out Cancellation form instead) Reactivate Category Change Upgrade ($40 per adult, $40 per up to three additional dependent children) DeactivateName Name Effective Date MM slash DD slash YYYY ReactivateName Name Effective Date MM slash DD slash YYYY Category ChangeFromCoupleFamilySingle AdultSingle Parent FamilySenior AdultSenior CoupleYoung AdultSilver SneakersPrimeRenew ActiveSilver Sneakers UpgradePrime UpgradeRenew Active UpgradeSummer CoupleSummer Single AdultSummer FamilySummer Single-Parent FamilySummer Young AdultToCoupleFamilySingle AdultSingle Parent FamilySenior AdultSenior CoupleYoung AdultSilver SneakersPrimeRenew ActiveSilver Sneakers UpgradePrime UpgradeRenew Active UpgradeSummer CoupleSummer Single AdultSummer FamilySummer Single-Parent FamilySummer Young AdultName of New Member/Member to Remove Date of Birth of New Member/Member to Remove MM slash DD slash YYYY Phone of New Member/Member to RemoveEmail of New Member/Member to Remove Address of New Member/Member to Remove Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Effective Date MM slash DD slash YYYY UpgradeName Effective Date MM slash DD slash YYYY Relationship to Primary Member Date of Birth of New Member MM slash DD slash YYYY Name Effective Date MM slash DD slash YYYY Relationship to Primary Member Date of Birth MM slash DD slash YYYY SignatureCAPTCHA Δ
