Your Name
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First Name
Last Name
Your E-mail Address
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Phone Number
YMCA You Would Most Frequently Visit
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Please Select
Don M. and Margaret Hilliker YMCA (Bellefontaine)
Delaware Community Center YMCA
Downtown YMCA
Eldon & Elsie Ward Family YMCA (Near East Side)
Gahanna/John E. Bickley YMCA
Grove City YMCA
Hilliard/Ray Patch Family YMCA
Hilltop YMCA
Jerry L. Garver YMCA (Canal Winchester)
Liberty Township/ Powell YMCA
North YMCA (Northland)
Pickaway County Family YMCA (Circleville)
Vaughn E. Hairston YMCA (Urbancrest)
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Date of Birth
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Month
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Day
Year
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Which membership option appeals to you?
2 adults + kids
1 adult + kids
2 adults
Adult (ages 30+)
Young Adult (18-29)
How do you hope to benefit from your Y membership?
How physically active are you?
Not at all
Seldom (1-2 times a week)
Regular (3-4 times a week)
Frequent (5-7 times a week)
Medically-based program
How did you learn about the Y?
Direct mail
Returning Member
Family/friends
Print ad
Radio station
TV station
Website / search
Employer
Healthcare provider
Company
Anything else you would like our membership advancement team know about you?
Branch Info
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Branch Staff
Branchphone
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