Assisted Membership Program Form Page 2
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1
2REQUEST FOR ASSISTED MEMBERSHIP
Name:
Birth Date:
Y
M
D
Address:
City:
Postal Code:
Phone Number:
Emergency Contact:
Phone Number:
Email:
Please check appropriate box for membership application. This is:
a new membership
a current membership
an expired membership
Please list the names of all household members. Please check yes/no for those who will be on the membership.
Name:
Birth Date:
Y
M
D
Yes No
Name:
Birth Date:
Y
M
D
Yes No
Name:
Birth Date:
Y
M
D
Yes No
Name:
Birth Date:
Y
M
D
Yes No
Total Gross Monthly Household Income*: $ ____________________________
Note: Income must include Wages, ODSP, Ontario Works, Child Tax Credit, Support Payments, EI Income, CPP
retirement pension and any other source of income.
Source*:
$
Source*:
$
Source*:
$
Source*:
$
*Must provide receipts and/or proper documentation
MONTHLY EXPENSES
Rent/Mortgage*
$
*Must provide receipts and/or proper documentation
Utilities (Hydro)
$
Household Items $
(Water) $
Transportation $
(Heat) $
Debt $
(Phone) $
Insurance $
In your opinion, how much do you think you can afford on a monthly basis? $__________________________
PLEASE BE AWARE THAT IT WILL TAKE 1 WEEK TO PROCESS YOUR APPLICATION.
I will certify that the above information is true and complete to the best of my knowledge. I agree to inform the YMCA
immediately of any changes in my income or family size. I understand that false or incomplete information could jeopardize my
financial assistance. I understand that only the information necessary to complete this application is requested.
Signature:
Date:
(OFFICE USE ONLY)
Fee $
x
Months = $
Staff
Signature:
Date:
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