Request For Scholarship Form - The Ymca Of Metropolitan Chicago

THE YMCA OF METROPOLITAN CHICAGO - BUEHLER YMCA

REQUEST FOR SCHOLARSHIP

PLEASE COMPLETE THE INFORMATION BELOW TO HELP US EVALUATE YOUR REQUEST:

Name:

Telephone:

Received:

Address:

City:

State:

Zip:

Number of people residing in the household: ________

Names and ages of all residing in the household:

ARE YOU CURRENTLY A BUEHLER YMCA MEMBER?

Yes

If yes, please put your membership number here: ________________________________________Expiration date: _______________

ARE YOU REQUESTING A REDUCTION IN MEMBERSHIP FEES?

Yes

If yes, check membership type desired:

Family

Adult

Youth (8-17 years of age)

What keeps you from paying the full amount? (reason for request)

________________________________________________________________________________________________________

What can you afford to pay each month?

$__________

ARE YOU REQUESTING A REDUCTION IN PROGRAM FEES?

Yes

If yes, check programs desired:

Aquatics

Youth Sports

Fitness

After school Care

Pre-School

Camps

Please be specific with class name and for whom:_________________________________________________________________

What keeps you from paying the full amount? (reason for request)_______________________________________________________

__________________________________________________________________________________________________________

______________________________________________________________________________________________________

What can you afford to pay for the program(s)?

$__________

DOCUMENTATION OF INCOME:

Please provided all information required; otherwise, your application will be

returned to you and delay the approval process.

What is the total annual income for your entire household? $_______________ (include salary information for ALL

working individuals in the household, child support, maintenance, social security, public assistance/food stamps,

etc.)

Attach copies of the following to document income:

Federal IRS 1040 for most recent tax year (NOT your W2 earning statement) AND whichever of the

following

items apply to your household:

Two most recent paycheck stubs for all who work

(not advices of deposit)

Social Security income verification letter

Public Assistance income verification letter

Public Assistance food stamps verification

YOUR REQUEST WILL NOT BE PROCESSED WITHOUT FINANCIAL DOCUMENTATION PROVIDED

STATEMENT BY APPLICANT:

I certify that all information provided to the YMCA of Metropolitan Chicago in this application for reductions are

true. I understand that false information will make me ineligible for any participation in the organization. I

understand that the decision to grant a fee reduction is the sole discretion of the Board or Managers or its

designee.

Signature of Applicant\Parent\Guardian: ___________________________________________Date: _____________

FOR OFFICE USE ONLY:

Membership: Total fees:

$________

Program:

Total fees:

$________

Amount to be waived:

$________

Amount to be waived:

$________

Amount to be paid:

$________

Amount to be paid:

$________

Approved by:

________

Approved by:

________

PLEASE RETURN TO: The Executive Director ⋅ Buehler YMCA ⋅ 1400 W. Northwest Hwy. ⋅ Palatine, IL 60067

Telephone: 847.359.2400

FAX: 847.359.2440

financial assistance application.wpd

Request For Scholarship Form - The Ymca Of Metropolitan Chicago - Buehler Ymca

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