Livestrong® at the YMCA

LIVESTRONG® AT THE YMCA

BERKELEY HEIGHTS YMCA
Tuesday & Wednesday, 6:00-7:15 PM

SUMMIT YMCA
Monday & Wednesday, 1:00-2:15 PM

For details on upcoming session dates visit www.thesay.org/livestrong
Participant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Ethnic Origin*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteTwo or More RacesPrefer not to say
Please note: Y-USA requests the above information from YMCA participants throughout the nation for program funding and demographic purposes.