First Name *

Last Name *

Email *

Location *

What is making you want to leave your Synergy fitness program? *

How would you describe your satisfaction with the facilities including equipment, parking, and accessibility? *

What was the original reason you joined? *

What could we do differently? *

How likely are you to recommend Synergy? *

Additional Comments/Questions: *

I understand that my membership will be canceled 7 days from the date this form was submitted.