LIVESTRONG at the Y Interest Form

LIVESTRONG at the YMCA Interest Form
LIVESTRONG at the YMCA is a free evidence-based program for adults currently living with or past cancer treatment and their caregiver. The program focuses on rekindling our relationship with our mind and body through strength, balance, flexibility, and connection with other survivors. The program meetings take place twice a week for 90-minutes each for a total of 12-weeks. All participants need to be medically cleared to participate.

Please note completing this form does not guarantee enrollment. A YMCA Care Coordinator will contact you to discuss the program, your goals, history and support connecting you to upcoming programming.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Preferred Phone Number*

Area CodePhone Number
Are you okay with receiving text messages regarding your interest in this program? (Data messaging rates my apply)stion

YesNo
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently undergoing cancer treatment?

YesNo
Are you a caregiver for someone who is currently living with cancer or completed cancer treatment?

YesNo
How did you hear of the LIVEStrong at the Y program?
Preferred YMCA Location
Should be Empty: