Healthy You, Healthy Relationships Event Registration
Event Timing: Tuesdays, June 7-28, 6:00-7:30
Event Address: 304 E. Third Street, Alton, IL 62002
Contact us at programs@ywcaswil.org or 618 465 7774 ext 206
Sign in to Google to save your progress. Learn more
Name *
Email *
Phone Number *
Your Date of Birth *
Emergency Contact Information: Name *
Emergency Contact Information: Telephone Number
Please mark which days you will attend. To receive the full benefits of the workshop, we recommend attending every class. *
Required
Will you require child care? *
If you require child care, please list the number of children and their ages. *
For sliding scale fees, demographic purposes, and grant reporting, please enter your annual household  income from all household members. *
Household size *
For demographic purposes and grant reporting, please identify your race/ethnicity. *
For demographic purposes and grant reporting, please check any forms of Public Assistance that your household receives. *
Classes are $15 each, $40 for all four, and sliding scale rates are available. We will notify you if you qualify for a sliding scale fee. I understand that I will have to pay upon arrival. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms