Community Health Interest Form | YMCA Western North Carolina

First Name

Middle Name

Last Name

Date of Birth

You can maually enter your DOB or use the calendar icon.

Phone

Primary Language (How can we better serve you?)

Are you a Y member?

What program are you interested in?

How did you hear about our programs?

What time do you need class?

At which YMCA location would you be interested in attending class? (Check all that apply)

Would you prefer if the class was virtual?

Additional Comments