ACT! Actively Changing Together

ACT! Actively Changing Together

Eating Well, Playing More
ACT! stands for Actively Changing Together and focuses on helping youth and families establish healthy habits and incorporate physical activity into their daily routines to aid in achieving a healthy weight. This evidence-based program aims to support families in adopting sustainable healthy habits together to live healthier lives.

This is a 12-week program that meets for 2-hours each week. ACT! is currently only offered in the Winter and Fall in Pierce County.

Please note that completing this form does not guarantee enrollment. A YMCA Care Coordinator will contact you to discuss the program, family goals and support connecting to upcoming program offering.
---------- CHILD'S INFORMATION
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Primary Phone Number*
Are you okay with receiving text messages regarding your interest in this program? (Data messaging rates my apply)

YesNo
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City

Zip Code
Today

MonthDayYear
Date
NumberOfDays
Age
---------- GUARDIAN INFORMATION
Your Name*

First NameLast Name
Relation to Child?*
How did you hear of the ACT! Program?
Is your household Spanish speaking?
Should be Empty: