Child Care Financial Assistance Application Form - Ymca

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CHILD CARE FINANCIAL ASSISTANCE APPLICATION
This application is not to be considered as a guarantee of financial assistance. Please print the information requested.
Current proof of income must be attached for consideration.
Please check the financial assistance area you are applying for:
SCHOOL AGE CHILD CARE: AGES 5-13
PRESCHOOL: AGES 2-5
❑ After School Age Child Care
❑ Summer Day Camp
❑ Full Day Preschool
❑ Before School Age Child Care
❑ Schools Out Day Camp
❑ Preschool Enrichment
❑ Late Start School Age Child Care
YMCA Child Care location or school child would attend ______________________________________________________________________________________________________________
Date ______________________________________________________________________________
Parent/Guardian First Name ______________________________________________
MI ________ Last Name ________________________________________________________________
Home Street Address _______________________________________________________ City ________________________________________________ State _________ Zip ____________
Home Phone __________________________________________________________________ Cell Phone ________________________________________________________________________________
Email ______________________________________________________________________________________________________________________________________________________________________________
DOCUMENTATION OF INCOME
Please provide all information required. Your request will not be processed without providing proof of your total household income.
Total monthly gross income for entire household $ _____________________
(Include proof of income for ALL household members, including child support, social security, public assistance/food stamps,
state and federal aid, unemployment, etc.)
OR
Please attach copies of the following:
❑ Two most recent paycheck stubs for all working individuals
❑ Federal IRS tax return for most recent tax year
❑ Social Security income verification letter
(1040,1040A,1040EZ)
❑ Public Assistance income verification letter
❑ W2 check stubs/forms
Date Received _______________________________ Staff Initials ________________________________ ❑ Approved ❑ Not Approved
FOR ADMIN
USE ONLY
Date Processed _____________________________ Program Session __________________________ Awarded ____________%
Child 1
________________________________________________________
Total Cost of Care $ ______________________________________________
Child 2
________________________________________________________
Less % Financial Assistance of $ _____________________________________
Child 3
________________________________________________________
Family Cost $ ______________________________________________
Child 4
________________________________________________________
Senior Admin Approval ___________________________________________________
Child 5
________________________________________________________
Senior Executive Approval ______________________________________________`
YMCA OF DANE COUNTY. INC.
revised 2 02 2015

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