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Corporate Challenge Information

Submitted by Anonymous (not verified) on Thu, 01/24/2019 - 10:02am

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Corporate Membership Form

Submitted by Anonymous (not verified) on Tue, 01/22/2019 - 4:44pm

First Name *

Last Name *

Company *

Email *

Select the nearest Greater Fort Wayne YMCA Facility *

Tell us what you might be looking for regarding the Greater Fort Wayne YMCA's Corporate Wellness plan. *

What components would you like as part of your program? Check all that apply.

Face-to-Face Health Coaching

On-site Fitness Facility Management

On-site Group Exercise classes

Employee Wellness Challenges and presentations

Incentive and point management systems

Disease Management Programs (Diabetes Prevention, Cancer Survivorship, Weight Loss & more)

Corporate Volunteer Opportunities

Corporate Membership Partners

Comments

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Blood Pressure Self Regulating Participant inquiry

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 2:54pm

First Name *

Last Name *

Address

(Indiana Resident Only)

Street Address *

City *

State *

Zip Code *

Phone Number *

Email *

Branch Preference *

Why are you interested in the Blood Pressure Self Regulating Program? *

Are you eligible?

Please confirm you fill the following requirements for the YMCA Blood Pressure Self-Monitoring Program:

Age *

Be at least 18 years old

Diagnosis *

Be diagnosed with high blood pressure

Cardiac event *

Not have experience a recent cardiac event

Atrial Fibrillation *

Not have atrial fibrillation or other arrhythmias

Lymphedema *

Not be at risk for lymphedema

Leave this field blank

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Blood Pressure Self-Monitoring

Blood Pressure Self-Monitoring Program

Take Action to Improve Heart Health

Free YMCA Membership for 7th Graders

Youth leader with three kids. Do you know a local 7th grader looking for a fun place to spend time with friends? Are you a parent looking to surround your teen with positive role models? If you answered yes, then contact your local Y about a FREE YMCA membership for your 7th grader. (Offer valid for residents of Adams, Allen, Wells, and Whitley counties.) No purchase necessary.

Livestrong Participant inquiry

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 1:02pm

First Name *

Last Name *

Street Address *

Address 2

City *

State *

Zip Code *

Phone number

Email Address *

Date of Birth

Month

Day

Year

Gender *

Emergency Contact

Emergency Contact phone number *

Are you currently a YMCA Member?

Have you been a YMCA member before? *

Yes

Which YMCA branch do you prefer?

How did you hear about LIVESTRONG® at the YMCA Program?

Do you currently have cancer or have you had cancer in the past? *

Yes

What type of cancer?

What are you looking for in a cancer exercise program? *

Leave this field blank

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Diabetes Prevention, Provider Referral

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 11:28am

Diabetes Prevention

Prediabetes Provider Referral

First Name *

Last Name *

Address

(Indiana Residents Only)

Street Address

Address Line 2

City *

State *

Zip Code

Phone *

Email *

Referring Provider *

Authorization *

I authorize that patient permission was received prior to submitting this online referral form to the YMCA's Diabetes Prevention Program.

Can they participate?

In order to qualify for the YMCA’s Diabetes Prevention Program, patients must be overweight (BMI > 25)* and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes.

Has the patient been told that they have prediabetes? *

Yes

Have they already been diagnosed?

If the patient has been diagnosed with prediabetes, please fill in the following applicable values.

Fasting Plasma Glucose

(must be 100 - 125 mg/dl)

2-hour

(75 gm glucola)

Random/Casual Blood Glucose

(must be 140 - 199 mg/dl)

A1c

(must be 5.7 - 6.4%)

Are they at risk for developing diabetes?

Please answer 'yes' if the following statements are true.

Their blood pressure is 140/90 or higher, or I have been told they have high blood pressure

Yes

They have been told that their cholesterol levels are not normal

Yes

They are fairly inactive. They are NOT physically active more than two times a week.

Yes

They have or had a parent or sibling with diabetes.

Yes

They have been told they have prediabetes

Yes

They have had gestational diabetes or gave birth to a baby weighing more than 9 pounds.

Yes

They are 45 years of age or older.

Yes

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