YMCA Abuse Questionnaire

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Were you or a loved one abused by someone affiliated with YMCA?*

Yes

What institution or entity were they associated with?

Approximately when did this happen?

If multiple months or years, choose the latest date the abuse occurred

Month happened

Month:

Year happened*

Year:

State the abuse occurred in*

Who are you reaching out for?

Select "Someone else" if you are reaching out for something that happened to your child

Myself

Someone else

Their full name*

Their date of birth*

Your relationship to them*

My child, my parent, etc

Is this person deceased?*

Yes

Their date of death*

Cause of death*

If they committed suicide, please list that

How old were you or your loved one at the time of the abuse?*

Your First Name*

Your Last Name*

Email*

Phone*

Zip Code*

Email List

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Yes

Questions? Call us at (214) 544-9692.