Health Plan Renewal or Enrollment Request

First Name
Last Name
Email
Phone Phone - ### - ### ####
Date of Birth Date of Birth / MM / DD YYYY
Health Plan Provider

Health Plan Provider HMSA Kaiser HMAA UHA UHC Other
Other Health Plan Provider

Please enter the name of your Health Plan Provider
Fitness Program (If Known)

Fitness Program (If Known) Active & Fit Silver & Fit UHC/Renew Active One Pass Aaptiv Other
Other Fitness Program

Please enter the name of your Fitness Program
2027 FITNESS ID or CONFIRMATION ID
[Contact your health plan for your ID number]
Or learn how to do so here
Your membership is valid at all Y locations on Oahu. What is the primary Y location you will be using?
Would you like to upgrade your Health Plan Membership?

Would you like to upgrade your Health Plan Membership? No Yes
Select your upgraded plan: Rates effective 1/1/2027

Select your upgraded plan: Rates effective 1/1/2027 Dual Adult $62 1 Adult Family $57 2 Adult Family $85 3 Adult Family $115 4 Adult Family $142
Did you visit our YMCA?

Did you visit our YMCA? Yes, I visited the Y this month. Please scan me in. No, I have not visited the Y yet. Please renew or enroll me first.
What is your Race/Ethnicity

What is your Race/Ethnicity African American or Black Asian Hispanic/Latino Middle Eastern or Northern African Native Hawaiian Pacific Islander White Race/Ethnicity Not listed here Prefer not to answer

Your responses will help our Y, as an impact charitable organization, continue to serve all in critical programs for youth, families, individuals of all ages, gender, backgrounds, and means.
What is your annual household income?

Your responses will help our Y, as an impact charitable organization, continue to serve all in critical programs for youth, families, individuals of all ages, gender, backgrounds, and means.
Please renew or enroll me in my Health Plan membership benefit using the information provided. I understand this does not guarantee eligibility and verification must be confirmed with my health plan administrator. I will be contacted to confirm my renewal and any additional information that may be required.
Please draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.