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Population Health Interest Form

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Parent or Guardian's Email Address

Email*

Confirm Email*
Yes, I would like to receive information from the Y.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you a member of the YMCA of WNC?*
Which program are you interested in?*
How did you hear about the YMCA's Population Health programs?*

If Other please Explain
What time do you need class?
Morning
Afternoon
No Preference
At which YMCA location would you be interested in attending class? (Check all that apply)
Asheville YMCA (Downtown)
Corpening Memorial YMCA (Marion)
Ferguson Family YMCA (Candler)
Hendersonville Family YMCA
Reuter Family YMCA (South Asheville)
YMCA at Mission Pardee Health Campus (Fletcher/Arden)
Woodfin YMCA (North Asheville)
Black Mountain
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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