YMCA Weight Loss Program
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Today's Date
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
NOTE:
You must be 18 years or older to submit this form.
Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your current weight (pounds)?
*
What is your height?
*
Please Select
4' 0"
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
How did you hear of the Weight Loss Program?
Please Select
Self (decided to on own)
Non-primary car health professional
Primary Care Provider/Office
Community-based organization/Community Healthcare Worker
YMCA Staff
Family or Friend
Employer or employer's wellness program
Insurance Company
Media (new, advertising or social media)
Are you currently an active YMCA of Pierce and Kitsap Counties member?
*
Please Select
Yes
No
Please select your preferred YMCA Location for programming?
*
Please Select
Haselwood YMCA (Silverdale)
Bremerton Family YMCA
Tom Taylor YMCA (Gig Harbor)
Morgan Family YMCA (Tacoma - Pearl St.)
Tacoma Center YMCA (downtown Tacoma)
Lakewood Family YMCA
Mel Korum Family YMCA (Puyallup)
Gordon Family YMCA (Sumner)
On-line via ZOOM
Please select your preferred time for programming
*
Please Select
Morning (8am-11am)
Afternoon (12pm-4pm)
Evening (5-7pm)
Submit
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