Community Health Programs
Know Your Health Survey and Interest Form
Interest Form
Name
*
First Name
Last Name
Phone Number
*
Email
*
P
l
e
a
s
e
i
n
d
i
c
a
t
e
w
h
i
c
h
p
r
o
g
r
a
m
(
s
)
y
o
u
a
r
e
i
n
t
e
r
e
s
t
e
d
i
n
n
o
w
,
f
o
r
t
h
e
f
u
t
u
r
e
,
f
o
r
a
f
a
m
i
l
y
m
e
m
b
e
r
:
Please indicate which program(s) you are interested in now, for the future, for a family member:
*
Interested Now
Interested for Future
Family Member Interested
Not interested
YMCA's Diabetes Prevention Program (Prediabetes)
Blood Pressure Self-Monitoring Program (High Blood Pressure)
LIVESTRONG at the YMCA (Cancer)
Walk with Ease (Arthritis)
Healthy Weight and Your Child (Childhood Obesity)
Back
Submit
Next
YMCA Staff ONLY
Patient is: contacted, waitlisted, enrolled, declined, withdrew, completed program
Contacted
Waitlisted
Enrolled
Declined
Withdrew
Completed Program
Submit
Should be Empty: