Confidential Application For Financial Assistance
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1
2CONFIDENTIAL APPLICATION
FOR FINANCIAL ASSISTANCE
Application Date: __________________________________
Please complete all of the following questions in full and attach the necessary documents (photocopies
only) and return to your branch of the YMCA of Greater St. Louis. Balance of the allocation must be paid
in full or on a monthly basis. Please print.
Name: __________________________________________________________________________________________________________________________________
_____________________
Address: _________________________________________________________________________________________________________
City: _____________________________________________________________________ State: _____________________ Zip: ___________________________
Home Phone: ______________________________________________________ Age: _____________ Birthdate: ________________________________
____________________
E-Mail Address: ________________________________________________________________________________________________
_____________
Place of Employment: ________________________________________________________________________________________________
Position: ________________________________________________________________ How long: _________________________________________________
_
Work Phone: ___________________________________________ Cell Phone: ______________________________________________________________
Emergency Contact Name: ________________________________________________________ Phone #: ___________________________________
Have you ever applied for financial assistance
Single Parent Household? q Yes
q No
before at the YMCA?
No
If yes, which YMCA?: ____________________________________________________
q Yes
q
Spouse/Child(ren) Names
Age(s)
School/Employer
Birth Date(s)
Your present gross (before taxes) income level is:
Application for financial assistance is for:
q Under $8,000
q $18,001-$20,000
q Membership
q Individual
q Family
q $8,001-$9,000
q $20,001-$22,000
q Program/Camp q Child Care*
q $9,001-$10,000
q $22,001-$24,000
q Other: _______________________________________________
q $10,001-$12,000
q $24,001-$26,000
*If this application is for child care/camp, you must have been
denied benefits from the Division of Family Services. Please attach
q $12,001-$14,000
q $26,001-$28,000
your denial letter with this application. Your application cannot be
processed until you submit a denial form. If you have applied for
q $14,001-$16,000
q $28,001-$30,000
benefits and have been put on a waiting list, you must show proof
q $16,001-$18,000
q Over $30,000
of waiting-list status.
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