Application for Financial Assistance          

Name _________________________ Address ________________________________

City __________________________ State ____________ Zip Code ______________

Home phone ___________________ Work phone _____________________________

Place of employment ____________________________________________________

Total family gross income ___________ Number of dependents _________

Scholarship request: (Please check) Membership ________ Program _________

Please describe how a YMCA membership or program can help you and/or your family members: ___________________________________________________________________________________

Please provide any additional information that may assist us in the decision whether to grant  financial assistance: (use back of  form if needed) ___________________________________________________________________________________

Please provide the following for all household members as appropriate: W-2 form, most recent tax return, paycheck records, information about child support or government assistance.

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Office use only:

Date _______________

Total YMCA assistance $__________ Participant contribution $___________

Percentage of assistance % ________ Membership category ______________

Program _______________ Review date __________ Staff ___________________