Request For Financial Assistance - Ymca Of Greater Oklahoma City
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1
2DATE __________________________________________
HOME BRANCH ______________________________
YMCA OF GREATER OKLAHOMA CITY
%
FOR STAFF USE ONLY
STAFF NAME__________________________________ SCHOLARSHIP AWARDED___________________
REQUEST FOR FINANCIAL ASSISTANCE
UNIT ID _______________________________________
SCHOLARSHIP EXP. DATE__________________
INSTRUCTIONS:
PRIMARY MEMBER: SECTION
ADDITIONAL ADULT: SECTION
2
4
6
1
7
8
3
5
PRIMARY MEMBER ON THE ACCOUNT
ADDITIONAL ADULT INCOME
1
2
NAME
(Please Print)
__________________________________________________________________________________________
PRIMARY MEMBER
(First)
(M.I.)
(Last)
(Please Print)
___________________________________________________________________________
EMAIL ADDRESS ______________________________________________________________________________________________________________
(First)
(M.I.)
(Last)
GENDER
Male
Female
ETHNICITY ____________________________
DOB _______________________________
PHONE (H) _______________________________________________________ (C) ______________________________________________________
(Month)
(Day)
(Year)
ADDITIONAL CHILDREN 23 AND UNDER
ADDRESS ______________________________________________________________________________________________________________________
Name _______________________________________Age__________
Name _______________________________________Age__________
CITY ______________________________________________________ STATE________________ ZIP CODE_______________________________
Name _______________________________________Age__________
Name _______________________________________Age__________
Name _______________________________________Age__________
Name _______________________________________Age__________
EMAIL ADDRESS ______________________________________________________________________________________________________________
GROSS MONTHLY INCOME
GENDER
Male
Female
BIRTHDATE ____________________________________________________
$____________________
EMPLOYMENT
$____________________
DISABILITY
(Month)
(Day)
(Year)
$____________________
CHILD SUPPORT
$_____________________
SCHOOL LOANS/GRANTS
$____________________
SOCIAL SECURITY
$_____________________
OTHER _________________________________________
$____________________
FOOD STAMPS
$_____________________
OTHER__________________________________________
ETHNICITY
Native American
Alaskan Native
African American / Black
ADDITIONAL ADULT MONTHLY GROSS INCOME TOTAL $ _________________________________________________________
Asian/Pacific Islander
Caucasian/White
Hispanic
Other
Ethnicity is collected for demographic purposes ONLY to ensure we are serving our entire community.
ADDITIONAL ADULT INCOME
ADDITIONAL CHILDREN 23 AND UNDER
3
Name _______________________________________Age__________
Name _______________________________________Age__________
NAME
(Please Print)
__________________________________________________________________________________________
(First)
(M.I.)
(Last)
Name _______________________________________Age__________
EMAIL ADDRESS ______________________________________________________________________________________________________________
Name _______________________________________Age__________
GENDER
Male
Female
ETHNICITY ____________________________
DOB _______________________________
Name _______________________________________Age__________
Name _______________________________________Age__________
(Month)
(Day)
(Year)
ADDITIONAL CHILDREN 23 AND UNDER
Name _______________________________________Age__________
Name _______________________________________Age__________
GROSS HOUSEHOLD MONTHLY INCOME
Name _______________________________________Age__________
Name _______________________________________Age__________
Name _______________________________________Age__________
Name _______________________________________Age__________
$____________________
EMPLOYMENT
$____________________
DISABILITY
GROSS MONTHLY INCOME
$____________________
CHILD SUPPORT
$_____________________
SCHOOL LOANS/GRANTS
$____________________
SOCIAL SECURITY
$_____________________
OTHER _________________________________________
$____________________
EMPLOYMENT
$____________________
DISABILITY
$____________________
FOOD STAMPS
$_____________________
OTHER__________________________________________
$____________________
CHILD SUPPORT
$_____________________
SCHOOL LOANS/GRANTS
$____________________
SOCIAL SECURITY
$_____________________
OTHER _________________________________________
$____________________
FOOD STAMPS
$_____________________
OTHER__________________________________________
PRIMARY MEMBER MONTHLY GROSS INCOME TOTAL $ _________________________________________________________
ADDITIONAL ADULT MONTHLY GROSS INCOME TOTAL $ _________________________________________________________
YMCA OF GREATER OKLAHOMA CITY
500 NORTH BROADWAY, SUITE 500 | OKLAHOMA CITY, OK 73102
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