UpTurn Registration - YMCA Northumberland

UpTurn Intake Form 2024

Please complete the Intake Form below to begin your membership process through the UpTurn Program at YMCA Northumberland, sponsored by the Ryan Huffman Foundation.

"*" indicates required fields

Date

Referral's Name*

Referral's Organization*

PERSONAL INFORMATION

Full Name*

First Last

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

SUPPORTING INFORMATION

Please select all that apply:

I am in recovery

I would like to experience the positive benefits of exercise

I want to feel more connection to the community

I have goals for my mental health

My financial resources are limited

This space is where you share information on why an UpTurn membership would benefit you (max. 250 char.).

Are you willing to attend a monthly meeting for all UpTurn Program Members?*

Yes

LEGAL DOCUMENTATION

We acknowledge the important step you have taken in registering for the UpTurn Program. As a final step to complete the registration process, please review the UpTurn Program Membership Contract document below regarding the terms and conditions and other important policies in effect as a member of YMCA Northumberland through the UpTurn program. Please note that your initial membership includes 3 Day Passes. It will be extended to a 1 Month Membership and then a 3 Month Membership based on your use and benefit from the program. Simply click on the document to open and review the PDF document in detail. You can also print it off. Once you have reviewed the document, please provide your consent by selecting “I agree” and inserting your name below. Thank you!

UpTurn Program Membership Contract

Full Name*

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