Idaho Falls Family Ymca - Application Form printable pdf download

Idaho Falls Family Ymca - Application Form

Idaho Falls Family YMCA

FINANCIAL ASSISTANCE INFORMATION FORM

Financial Assistance Information Form

APPLICANT INFORMATION:

Name: _____________________________________________________________

Date:___/____/____

Last

First

Address:_______________________________________________________________________________

Street Address

City/Zip Code

Phone: ________________________ Birthdate_____/_____/_____

Type of Membership: ___Adult

___Family ___Senior ___Student/Youth ___Program Only

Program:___________________________________________(Please be specific)

YMCA membership, class or program fees will be awarded to deserving applicants based on the available financial resources of the association.

PLEASE INCLUDE:

Copy of most recent tax return (1040 form)

Copy of two most current consecutive paycheck stubs for all working members of household

Documentation of SSI/SSD, food stamps, child support or unemployment benefits (or any

other form of income)

Documentation of student status

NOTE: Your application will not be processed until ALL necessary forms are received.

ADDITIONAL INFORMATION:

Names and birthdates of all other members of household:

1._________________________________________________

_____/_____/_____

2._________________________________________________

_____/_____/_____

3._________________________________________________

_____/_____/_____

4._________________________________________________

_____/_____/_____

5._________________________________________________

_____/_____/_____

*Individuals who can be included in a family unit receiving financial assistance are only those claimed on current tax returns.

If you would like, you may briefly describe your need for financial assistance here

______________________

_______________________________________________________________________________________________

Applicant Signature:_____________________________________________

Date:____/____/____

Idaho Falls Family Ymca - Application Form