Refund Request Form
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which item(s) would you like refunded?
*
Graduate Student Membership
Faculty/Staff Well Membership
Affiliate Well Membership
Personal Training session(s)
Other
Order ID Number(s) associated with the purchase(s) you want refunded
*
Find your Order ID Number in the email confirmation you received at the time of purchase.
Why are you requesting a refund?
*
Submit
By clicking the “Submit” button, I consent to be contacted via email.
Should be Empty: