Financial Assistance Application Form Page 2
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2FINANCIAL ASSISTANCE APPLICATION
Applicant's Name: ______________________________________________________________________________________________________________________________________________________
Participant's Name: ____________________________________________________________________________________________________________________________________________________
Financial Assistance requested for m Self m Child m Family Y Location: ____________________________________________________________________
Have you ever applied for financial assistance at The Community YMCA? m Yes m No
If so, which location? __________________________________________________________________________________________________________________________________________________
Amount received? ______________________________________________________________________________________________________________________________________________________
Please select: m New Applicant m Renewal of Previous Scholarship
APPLICANT OR PARENT
Name: ___________________________________________________________________________________________________________________________________________________ m M or mF
E-mail Address: _________________________________________________________________________________________________________________________________________________________
Home Phone: ________________________________________________________________ Work/Mobile Phone: _____________________________________________________________
Address: __________________________________________________________________________________________________________________________________________________________________
City: ____________________________________________________________________________ State: ________________________________ Zip: _______________________________________ _
Employer: _________________________________________________________________________________________________________________________________________________________________
Employer's Address: ____________________________________________________________________________________________________________________________________________________
Marital Status: m Single
m Married
m Divorced
m Widowed
m Domestic Partnership
Household:
m Single Adult
m Single Adult + Child/Children
m Two Adults
m Two Adults + Child/Children
m Other Family Household (Grandmother/Foster/Other)
List all Household Members, including Applicant/Parent, Siblings, and/or Spouse/Partner and all other adults
First Name
Last Name
Gender
Age
Relationship to Applicant
1. Applicant: _____________________________________________________________________________________________________________________________________________________________
2. Spouse/Partner: _____________________________________________________________________________________________________________________________________________________
3. Child 1: _________________________________________________________________________________________________________________________________________________________________
4. Child 2: ________________________________________________________________________________________________________________________________________________________________
5. Child 3: ________________________________________________________________________________________________________________________________________________________________
6. Child 4: ________________________________________________________________________________________________________________________________________________________________
7. Any other adult(s) who reside(s) in home:
_______________________________________________________________________________________________________________________________________________________________________________
Briefly explain your needs for financial assistance* and the program** in which you are interested:
____________________________________________________________________________________________________________________________________
(attach additional sheets if needed)
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
*Medical note may be required.
**Not all programs are eligible for financial assistance.
ACKNOWLEDGEMENT
I declare that the aforementioned statements are true and correct. If requested, I will provide further substantiation of facts. I hereby authorize
The Community YMCA to obtain employment income verification from my employer. I agree to inform The Community YMCA of any material
change in my financial status and employment prior to and during my membership and/or participation.
Applicant's Signature: _________________________________________________________________________________ Date: _________________________________________________________________________
Branch: __________________________________ Date: _______________________ Name: _____________________________________ Member #: _______________________________
1014-501E-FD
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