Pay It Forward Nomination Form

This nomination form is shared only with The Fort Madison Family YMCA management team and board of directors. Your nomination will remain a secret to the individual or family you nominate. If chosen you and your Nominee will be contacted and together you will have the opportunity to celebrate together when presentations of the memberships are awarded.

Nominator Name *

First

Last

Nominator Email *

Nominator Phone Number *

XXX-XXX-XXXX

Are you a current YMCA Member or have you ever held a YMCA Membership in the past?

*You do not have to be a member to nominate

Nominee Name *

First

Last

Nominee Email

Please provide the nominee’s email address if known

Nominee Phone Number's *

Please list all phone numbers that we may reach the Nominee at using a comma to separate multiple numbers. Example: xxx-xxx-xxxx, xxx-xxx-xxxx

Nominee Address *

Please include full address of the nominee

Nominating for: *

Family Membership
Individual Membership
Youth Membership

Age of Nominee or Number of Family Members *

Please list your nominee’s age or the number of people residing in the household of the Family you are nominating

Please tell us why your Nominee will be a good candidate for the Pay It Forward Program *

FORT MADISON FAMILY YMCA

Your Health On Your Time

PERSONAL TRAINING

STEAK FRY FUNDRAISER

Your Health On Your Time

PERSONAL TRAINING

STEAK FRY FUNDRAISER

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