Open Doors Scholarship Application Form - Ymca Of Ithaca & Tompkins County
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1
2For office use:
YMCA of Ithaca &
Date submitted: __________
Welcome Center Rep Initial: _______
Tompkins County
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nd
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use _________
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use _________
Open Doors Scholarship Application
Confirmation of no change in information:
Signature: ________________________
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3
use __________
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use __________
Please check: ___Applying for the first time ___Renewing application
What is the Membership Type you are applying for:
____Youth ____Junior ____Adult ____Senior ____College Student
____2 Adult Family ____2 Adult Family w/ children ____Senior 2 Adult Family ____College Student Family ____1 Adult Family w/ children
Primary Applicant Information:
Name: _______________________________________
Phone: _____________________________
Email: _________________________________
Address: __________________________________________________________________
City: __________ State: _______
Zip: ____________
Mailing Address (if different from above): __________________________________________________________________________
List everyone who lives in your household:
Gender
First & Last Name
Date of Birth
Additional Program Requested
M/F
SELF (Primary Applicant)
Please explain why you would like a membership at the YMCA
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I understand that this application does not guarantee that I will receive assistance.
- I understand that the terms of assistance are only good for 3 calendar months.
If not utilized in the 3 month term, the scholarship will be considered void.
- Paperwork must be resubmitted after one year, unless requested earlier due to change in living situation.
After 6 months we will review your information to ensure it is accurate and up-to-date. During the review
process we reserve the right to increase the scholarship amount.
- Processing applications can take up to 7-10 business days. Replies will be sent via email/mail.
- Not all programs qualify for scholarship.
Approved ___________
Denied ____________
For office use ONLY:
Membership Type: _____________________________________
3 Month ____ Annual ____
Bank Draft ____
Membership Cost: $_____________
YMCA Assistance: $___________________
Applicant Fee: $___________________
Program Type & Session Dates: __________________________ YMCA Assistant: __________% Applicant Fee: ___________%
Please continue on the reverse side to complete the application.
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