STRENGTHENING OUR COMMUNITY Financial Assistance ... - Ymca

CONFIDENTIAL APPLICATIONMembership %:Program %:Please submit copies of Federal Income Tax and other forms of income(1040 Form and two most recent consecutive paycheck stubs with this application)APPLICANT INFORMATIONYour NamePhoneAddress City State ZipHousehold Size: Adults ChildrenName of person(s) for whom financial assistance is being requested:1. Birthdate 4. Birthdate2. Birthdate 5. Birthdate3. Birthdate 6. BirthdateAre you or anyone listed above currently a YMCA member?If yes, at which location?Yes NoType of membership for which you are requesting financial assistance. (Please check one):Household Single Parent Household Adult Young Adult19-22Youth0-18Senior HouseholdSenior Adult62 & olderProgram(s) for which you are requesting financial assistanceHOUSEHOLD INCOME (Required to process the application)Monthly income from all adult household wages and salaries before taxes and other deductions. Adult 1 $Adult 2 $Other Income (public assistance, child support, food stamps, social security, disability, rent assistance, etc.) $Total Monthly Income $What was your household’s total gross income for last year? $CERTIFICATION OF NEEDOur financial assistance program is made possible by countless volunteers who reach out to the community and raisemoney for our Strong Kids Campaign. Please explain why you would like to be considered for financial assistance at theYMCA and what it would mean to your family. (Use additional page if needed)I certify that the above information is true and complete to the best of my knowledge. In addition, I understand that my/ourmembership privileges are subject to the same policies of a full membership. I understand that if I do not provide the requireddocumentation within 30 days of joining, my membership rates will revert to the standard monthly rates.SignedDate