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YMCA Weight Loss Program Fully Funded Class for American Indian/Alaskan Native Community Members
Enrollment Form
Date
*
-
Month
-
Day
Year
Date
Contact information
Legal Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name you wish to be called in class
*
Date of Birth: MM/DD/YYYY
*
Gender
*
Male
Female
Non-Binary
What pronouns do you use?
Example: "he/him", "she/her", or "they/them"
Email
*
Phone
*
Emergency Contact Name
Emergency Contact Phone
Demographics
RACE -- You may check more than one box. If there is an identifier not included in this brief list that would feel more appropriate, please feel free to use the "other" box and it will automatically open a free-text box to add an identifier of your choosing.
White or Caucasian
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Middle Eastern or North African
Other
Are you of Hispanic, Latino(a), or Spanish origin?
Yes
No
Highest educational or professional degree earned:
Less than high school
High school diploma or equivalency (GED)
Associate's degree (junior college)
Bachelor's degree
Master's degree
Doctorate
Professional (MD, JD, DDS, etc.)
Other
Pre-Program Survey
Score each statement on a scale of 1-5
I am confident in my ability to set and attain reasonable goals to achieve my desired long-term outcome.
*
Please Select
5 -- Strongly Agree
4 -- Agree
3 -- Neutral
2 -- Disagree
1 -- Strongly Disagree
I am confident in my ability to maintain an exercise routine independently.
*
Please Select
5 -- Strongly agree
4 -- Agree
3 -- Neutral
2 -- Disagree
1 -- Strongly disagree
I am confident in my ability to track my food intake.
*
Please Select
5 -- Strongly agree
4 -- Agree
3 -- Neutral
2 -- Disagree
1 -- Strongly disagree
I am confident in my ability to modify my food intake in ways that support my weight loss goals (e.g., portion control, avoiding emotional eating, choosing nutrient-dense foods, etc.).
*
Please Select
5 -- Strongly agree
4 -- agree
3 -- Neutral
2 -- Disagree
1 -- Strong disagree
Consent
I give consent to receive email communication from YMCA of the USA for the purpose of evaluating the Weight Loss Program.
*
Yes
No
As a leading nonprofit improving the nation’s health, the Y supports all individuals in achieving their health goals. The Y is always striving to learn more about program improvement. To that end, we are requesting your permission to collect your participation data. This data will consist of the above demographic data, weekly attendance, associated weekly weight and pre and post surveys. Data will be anonymized and not attached to your name. I acknowledge data from this program will be collected by the local YMCA and may be shared with YMCA of the USA for purposes of evaluating and improving the Weight Loss Program. I authorize and acknowledge that I have read, understand, and agree to the above.
*
Agree
I acknowledge and agree that submission of this form electronically shall serve in the same capacity as if I had physically signed a paper document.
*
I agree
Signature
Submit
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