Getting Ahead Class Application
This is not a sign-up. After completing this application, you will be contacted by YMCA staff to conduct an intake interview.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
What is the best way to communicate with you?
*
How many adults live in your household?
*
How many children live in your household?
*
Please list all adults ages 18 and older in your household, with their ages, names and genders:
*
Please list all children ages 17 and younger in your household, with their names, ages, genders and grade in school (if applicable):
*
Please select any race/ethnicity that you identify with:
*
White/Caucasian
Black/African American
Native Hawaiian/other Pacific Islander
Latino
Indigenous American
Prefer not to disclose
Are you Hispanic?
*
Yes
No
Prefer not to disclose
Please indicate your transportation situation:
*
I have transportation that can get me to the Getting Ahead classes regularly
I do not have transportation and the $25 transportation stipend will get me to the class
I do not have transportation and will need to be transported to and from the class
Please share any food allergies, sensitivities or dietary restrictions, you or your family has (NA if there are none):
*
How did you hear about Getting Ahead classes at the Y?
*
Why are you interested in participating in the Getting Ahead classes?
*
Submit
Should be Empty: