Ohio-West Virginia State YMCA Participant Data Form

If you have been a participant in any of our programs or in some way have been involved with the Ohio-West Virginia State YMCA as a volunteer, friend, supporter, or in whatever capacity, we'd love to hear from you. Please take a few moments to complete this data entry form and let us know about your involvement.

Your Name:	First: Middle Initial: Last: Maiden Name:
Mailing Address:	Street: City: State: Zip:
Phone:
E-mail Address:	Primary: Secondary:
Gender:	Male: Female:
Are you Registered on Facebook.com?	Yes No
Year of High School Graduation:
College Attended:
Year of College Graduation:
Current Occupation:
Are you Active in your Community?	Yes No
If YES, Please Explain:
HI-Y Involvement:	HI-Y Name: Name of School: Advisor: Yes No
I was a Participant in:	Ohio Youth in Government in year(s) Office Held: West Virginia Youth in Government in year(s) Office Held: Ohio Fall Conference in year(s) West Virginia Fall Conference in year(s) United Nations in year(s): Office Held:
I was at Camp Horseshoe:	Free Enterprise Leadership Camp in year(s): HI-Y Leadership Camp in year(s): Leadership-Service Camp in year(s): Adventure Camp in year(s): YOC Camp in year(s):
Other Program or Camp Participation	in year(s)
Haven't been a Program Participant but have been:	Friend of the Leadership Center Contributor Volunteer
Tell Us What You've Been Doing or send us your Comments/Questions:

Note: Your name, school, leadership position, participation dates and email address will be published on this site so that you may keep in touch with other Ohio-West Virginia YMCA friends.

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Ohio-West Virginia State YMCA HI-Y Leadership Center
P.O. Box 239 Pt. Pleasant, WV 25550
304.675.5899

The Ohio-West Virginia State YMCA, operating as the HI-Y Leadership Center is a 501(c)(3) not-for-profit organization.
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