Access Scholarship Application Form printable pdf download

YMCA of Greater Boston

ACCESS Scholarship Application

Name: ___________________________________________________________________________________________________ Membership Number: ______________________________________

Address: _______________________________________________________________________ City: ______________________________________ State: _______ Zip Code: ___________________

Date of Birth: _________________________________________ E-mail: ___________________________________________________________________________________________________________

Phone: Day ____________________________________________ Evening ___________________________________________ Cell Phone ___

__ _____________________________________

Your Employer’s Name & Address: ______________________________________________________________________________________________________________________________________

Financial assistance requested for:

Instructional Program_____ Camp____ Early Education & Out-of-School Time Programs____

Program Membership_____ Other_____

Spouse’s Name: ________________________________________________________________________________________________________ Date of Birth: ______________________________

Spouse’s Employer’s Name & Address: ____________________________________________________________________________________________________________________________

Your Annual Adjusted Gross Income $

Spouse’s Annual Adjusted Gross Income $

Child Support Income $_________________________ Other Income (source & amount) ______________________________________

Number of Family Members: _______________ (proof of family size may be required)

1. _____________________________________________ Date of Birth_____/____/_____

4. ____________________________________________________ Date of Birth_____/____/_____

2. _____________________________________________ Date of Birth_____/____/_____

5. ____________________________________________________ Date of Birth_____/____/_____

3. _____________________________________________ Date of Birth_____/____/_____

6. ____________________________________________________ Date of Birth_____/____/_____

List any special circumstances highlighting your reason for need:

Yes, I am willing to share my Y story with the YMCA to help support the Annual Reach Out campaign.

To qualify for ACCESS you must submit the following documents:

•

Complete ACCESS application

•

social security numbers will be redacted

Household income from most recent tax return (1040, not W2)

AND

•

One month proof of recent income (paystubs), or other proof of your current combined household income (SSI/SSDI)

•

Other proof of income verification may be required and/or accepted at the discretion of the YMCA, i.e. signed letter from your

employer, on your employer’s letterhead with the weekly income you earn.

The information listed on this form is correct to the best of my knowledge. I understand that the financial assistance granted to me by the YMCA of

Greater Boston must be re-applied for annually, from the date of this application, or as requested by the YMCA. I understand it is my responsibility to

reapply and that the YMCA will send out a financial assistance expiration notice 30 days prior to expiration. If I do not re-apply for financial assistance

my fees will be charged at the full-published rate.

Applicant Signature: ____________________________________________________________________________________

Date: _________________________________

************************** FOR OFFICE USE ONLY **************************

Program / Program Membership:

Early Education &Out-of-School Time Programs/Camp

Subsidy

Scholarship Code __________

Subsidy

Scholarship Code _________

Begin Date _________________

Begin Date ______________