Open Y Scholarship Application Form - Ymca Of Columbia Page 2
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2YMCA of Columbia
Open Y Scholarship Application
Please check which program you are requesting Financial Assistance for:
Membership
Childcare
(check to indicated which program: __Day Camp __ Preschoo l
__After-School ___Homeschool)
Aquatics
Youth Sports
Swim Team
PLEASE PRINT CLEARLY
Applicant’s Name: ___________________________________________ Date: ________________________
Mailing Address: ____________________________________________ City: _______________ Zip: ________
Home Phone: ______________________ Work Phone: __________________ Cell Phone: _______________
Email Address:
______________________________________
Number of Adults in household: _________
Please list all persons living in your household (do not include yourself)
Want on membership?
circle one to indicate
Name: _________________________ Relationship: _________________ Date of Birth _______________
Yes / No
Name: _________________________ Relationship: _________________ Date of Birth _______________
Yes / No
Name: _________________________ Relationship: _________________ Date of Birth _______________
Yes / No
Name: _________________________ Relationship: _________________ Date of Birth _______________
Yes / No
List any additional family members on reverse side of this application
Number in Household (counting yourself) __________________
Additional Questions:
Y/N
Indicate $ amount
1. Are you currently receiving monthly income for?
____ Food Stamps
____________________
____ Child Support
____________________
____ Welfare benefits
____________________
____ Social Security (SSI)
____________________
nd
2. What is your total monthly income? __________________
2
Adult income? __________________________
nd
What is your total annual income? ___________________
2
Adult income? __________________________
3.
4. Are you currently employed?
Name of current employer? ___________________________
(circle one)
YES / NO
5. Is the any other person on application currently employed?
(circle one)
YES / NO
If so list name of person and name of current employer for each? ____________________________________
A letter explaining your need for financial assistance must be attached. By you providing as much information as possible on
your extenuating circumstances, the Y’s committee will have a better understanding of your circumstances while reviewing your
application.
By signing below, I agree to notify the YMCA of any changes in my circumstances within 30 days of change. I understand
that if I submit false or inaccurate information, or fail to notify the YMCA within 30 days of changes, I may be cancelled
from the program at the YMCA’s discretion without notification. I understand that should I be approved for the YMCA
Open Y Program, that the approval will be good for one year from date of approval. I agree to reapply and be re-
evaluated, as requested, in order to continue in the Y’s Open Y program. Failure to comply with requested re-evaluation
will result in cancellation of your financial assistance and all membership dues and program dues will revert to full cost.
By signing below, I verify the information submitted is correct, complete and accurate
What can you afford to pay monthly? ______________
(must be completed and cannot be zero)
Applicant’s Signature: _______________________________________________ Date: __________________________
FOR OFFICE USE ONLY
Date of review: __________ Total Income Listed:
_____________
Deductions:
______________
Qualifying Income: _______________
Special Circumstances: _______________________________________________________________________________________________
Program approved for:
_________________ % of Scholarship: __________
Monthly amount to be paid for program: ____________
Approved by: _______________________________________________ Title: ___________________________________
Unit ID # in DAXKO: ___________________
Reevaluation date: ______________________
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