a scene of 2 children and a supervisor having a joyful lnch

Financial Assistance Application Form

Financial Assistance Application Form

You're always welcome at the Y! Apply for financial assistance with membership, Summer Day Camp, Holiday Camp, Afterschool Care, youth sports, group swim lessons, and year-round and summer swim teams*. We will follow up with you on the status of your application. *Please note all other programs are not eligible for financial assistance.

"*" indicates required fields

PRIMARY ADULT

Enter information for the Primary Adult on your membership account.
Name*
Address*
Please list the name of an emergency contact
(area code) phone number
Are you age 60 or over?*
Are you Active Duty Military?*
Please select your branch:*
Please select which type of Financial Assistance you are applying for*
Select all that apply

SECOND ADULT

Enter information for a second adult on your membership account. The second adult must live in the same household with you.
Name

DEPENDENTS/ADDITIONAL MEMBERS

List the full names and birthdates of other members living in the same household. Click the plus (+) sign at the end of the row to add more household members.
Additional household member names and birthdates*
First Name
Last Name
Birthdate
Ethnicity/Race
Gender
 
List the full name, birthdate, ethnicity/race, and gender for each dependent or additional household member. Use the date format MM/DD/YYYY. If there are no dependents, type NA.

MEMBERSHIP FINANCIAL ASSISTANCE

Choose the type of membership for which you are applying.
This field is hidden when viewing the form
Enter a dollar amount that you or your household can afford to pay monthly for a YMCA membership or program. Please do not enter $0.
Membership Types

HOUSEHOLD INCOME

All personal information will be kept confidential and secure. If additional documentation or clarification is required, a YMCA representative will contact you directly.
Enter the amount from your last tax return, Form 1040.
Did you file a tax return this year?*
Drop files here or
Accepted file types: pdf, jpg, png, doc, Max. file size: 250 MB, Max. files: 3.
    Please attach a copy of your 1040 tax form, or documentation from the options listed above. You may upload a .pdf or Word .doc if using a laptop or home computer. You may also take a photo of your letter or document and upload it.

    CERTIFICATION OF INFORMATION

    Secret Link