Community Health Interest
Please complete the form below and a member of our team will reach out to you about enrolling in the program. If you have questions, you can also contact our Health Equity Director at 918-728-3934
Name
*
First Name
Last Name
Gender
*
Preferred Pronouns
*
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to send text messages to this number?
*
Yes
No
Is it okay to leave a voicemail at this number?
*
Yes
No
Email
*
Are you currently a Y member?
*
Yes
No
Which community health program are you interested in?
*
LiveStrong at the YMCA
Diabetes Prevention Program (must be at risk for or have a diagnosis of prediabetes)
Blood Pressure Self-Monitoring Program (must be diagnosed with hypertension)
Diabetes Empowerment and Education Program (must be diagnosed with diabetes or a caretaker of someone with diabetes)
Courage to Quit Tobacco Cessation Program
Pedaling for Parkinson’s Classes
Walk with Ease
How were you referred to this program?
*
Physician or healthcare provider
Employer
I learned about it at the Y
Other (please specify)
Submit
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