Scholarship Application Form - Ymca Of The Fox Cities Page 2
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3YMCA Application for Scholarship Assistance
Name_________________________________________________
Date of Birth ____________________
(Last)
(First)
Address ___________________________________ City __________________ Zip __________________
Home Phone_______________ Work Phone_________________ Emergency Phone_________________
E-mail __________________________________________________________________________________
Employer________________________ Occupation______________________ Hours per week_________
Spouse/Partner __________________________________________
Date of Birth ___________________
Employer________________________ Occupation______________________ Hours per week_________
Are you a Single Parent Household?
o Yes
o No
Marital Status: o Single o Married o Divorced o Separated o Widow/Widower
Do you have an active membership?
o Yes
o No
List all household members (including other adults):
Name
Date of Birth
Sex
Relationship
___________________________ ____/____/____
___
______________
___________________________ ____/____/____
___
______________
___________________________ ____/____/____
___
______________
___________________________ ____/____/____
___
______________
___________________________ ____/____/____
___
______________
___________________________ ____/____/____
___
______________
Please check the program you are applying for:
o Preschool o Day Care o School Age
Please check the YMCA Branch or Location of the program:
o Appleton YMCA o Child Learning Center o Fox West YMCA o Heart of the Valley YMCA
o Neenah-Menasha YMCA
I have read the above Application for Scholarship Assistance and declare under the penalties of perjury that to the
best of my knowledge and belief the information supplied in this application and all accompanying statements of
documents is true and correct. This application is a complete statement of all income, assets or resources
belonging to me or to any member of the household. Failure to provide any form of income or changes of income
may result in the termination or delay of a scholarship from the YMCA.
Subsidies will be granted to the extent funds are available. The YMCA must reserve the right to refuse assistance
to any applicant. Scholarships will be reviewed for eligibility every six months.
Signature _______________________________________ Date __________________________
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