Membership Application Form Page 4
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4Current Exercise Pattern:
__ Caldwell
__ Downtown
Regular Exerciser
New to Exercise
Start/Stop Exerciser
Non-Exerciser
__ West Y City
__ Homecourt
Interests:
__ Staff
Aquatic Fitness
Diabetes Prevent
Personal Training
Teen Programs
Camp Horsetheif
Family Activities
Recreation/Lap Swim
Triathlon Club
Cancer Program
Family Pool Time
Strength Training
Yoga/Pilates
Cardio
Fun Run/Triathlon
Swim Fit
Youth Art & Science
Child Care
Group Exercise
Swim Lessons
Youth Programs
Child Watch
Nutrition
Swim Team
Youth Sports
Cycling
Older Adult Fitness
Other:
________________________________________________________
Barriers or Challenges to Wellness: ___________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Additional Questions or Comments: __________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Wellness for Life:
Wellness for Life Appointment can be the support that you need as you seek better health and well-being, and it is free to
members. In your initial appointment, you will work witha Health and Wellness coach on a one-on-one basis to come up
your wellness coach periodically for guidance and support until you are comfortable to move forward on your own. With your
coach, you may cover any of a variety of wellness topics, programs and opportunities available at your YMCA.
For Office Use Only
Date of application:
__________________________________________
Master Identification:
__________________________________________
Staff who set up account: __________________________________________
Prorated dues
$ _____________
Joining fee
$ _____________
Towels
$ _____________
Child Watch
$ _____________
Locker
$ _____________
Subtotal
$ _____________
Sales tax
$ _____________
TOTAL PAID AT APPLICATION
$ _____________
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