Child Care Financial Assistance Application Form - Ymca Page 2

Check box if

Check box if

List all persons living in household (including other adults and yourself)

currently

child is age 2-13

employed

and requesting

or receiving

Financial

income

Assistant

__________________________________________________________________________________________________________ _______________ __________________________________________

❑ Y ❑ N

❑ Y ❑ N

First Name

Middle Initial

Last Name

DOB

Relationship to Applicant

__________________________________________________________________________________________________________ _______________ __________________________________________

❑ Y ❑ N

❑ Y ❑ N

First Name

Middle Initial

Last Name

DOB

Relationship to Applicant

__________________________________________________________________________________________________________ _______________ __________________________________________

❑ Y ❑ N

❑ Y ❑ N

First Name

Middle Initial

Last Name

DOB

Relationship to Applicant

__________________________________________________________________________________________________________ _______________ __________________________________________

❑ Y ❑ N

❑ Y ❑ N

First Name

Middle Initial

Last Name

DOB

Relationship to Applicant

__________________________________________________________________________________________________________ _______________ __________________________________________

❑ Y ❑ N

❑ Y ❑ N

First Name

Middle Initial

Last Name

DOB

Relationship to Applicant

Does your child or family have a situation that you would like us to consider?

❑ Yes ❑ No

If yes, please explain

(You may attached additional information if needed): ___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you currently receive or qualify to receive Child Care funding assistance?

❑ Yes ❑ No

If yes, please provide agency name _______________________________________________________________________________________________________________________________________

Have you applied for Dane County funding? ❑ Yes ❑ No

If yes and have been denied, please attach your denial letter from Dane County Work Program of the Department of Human

Resources with this application. If no, please visit and apply. Turn in denial or approval letter. This

scholarship application will not be processed without a denial letter from County/WI Shares.

If no, please visit and click on “Am I Eligible?” to see if you may be eligible for state child care

assistance. If it looks like you may qualify for child care assistance, you can go ahead and apply. If it looks like you will not qualify

for child care assistance, you can print the determination. You can also check the income limits and requirements for the state

child care assistance program by using the following link “Day Care Manual.”

(MUST BE FILLED IN) I would like it taken into consideration that I feel I can afford to pay $__________________ each month towards Child Care.

I understand that the amount I feel I can afford may not be the amount I qualify for or am awarded.

The YMCA is not responsible for returning any documentation that accompanies this application. Please ensure that you have kept all of

your original documents.

Mail completed application to:

Lussier Family East YMCA.

711 Cottage Grove Road, Madison, WI 53716

TERMS AND CONDITIONS

Please read through each of the statements below. This section must be signed for your application to be reviewed.

•

You must provide proof of your total household income.

•

Financial Assistance is awarded for the duration of the program (i.e. school year or summer). When your child’s financial assistance

expires, please reapply with current income verification.

•

Family is responsible for their Child Care tuition by either making monthly payments through automatic withdrawal by credit card or

bank account. A 2 week notice is required to terminate enrollment.

•

The Y believes a strong sense of ownership and pride is developed if the financial assistance recipient has contributed to the cost of

their Y Child Care.

•

The maximum amount of financial assistance is 50% of program cost.

•

The YMCA of Dane County prohibits any form of discrimination based on race, color, creed, sex, religion, national origin, age, disability,

veteran’s status, marital status or any other prohibited basis as defined by law. This applies to all employment and scholarship

decisions. Discrimination will not be tolerated by employees, members, program members, suppliers, or consultants.

I have read and understand the Terms and Conditions stated above:

Applicant’s Signature _________________________________________________________________________________________________ Date ______________________________________________