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Financial Assistance Application Form

You're always welcome at the Y! Apply for financial assistance with membership and programs. We will follow up with you on the status of your application.

PRIMARY ADULT
Enter information for the Primary Adult on your membership account.
Name*
First Middle Last
Date of Birth for Primary Adult*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email Address*
Emergency Contact*

Please list the name of an emergency contact
Emergency Contract Phone Number*

(area code) phone number
Are you age 65 or over?*
- Yes
- No
Are you Active Duty Military?*
- Yes
- No
Please select your branch:*
- Downtown Express YMCA
- Southeast Family YMCA
- Hogan Family YMCA
- YMCA Camp Cha-La-Kee
SECOND ADULT
Enter information for a second adult on your membership account. The second adult must live in the same household with you.
Name
First Middle Last
Date of Birth for Second Adult
MM slash DD slash YYYY
Phone
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

List the full name and birthdate for each dependent or additional household member. Use the date format MM/DD/YYYY.

MEMBERSHIP FINANCIAL ASSISTANCE
Choose the type of membership for which you are applying.
The maximum amount I can afford to pay for a monthly membership or program is:*

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
- Individual
- Adult +1 (two adults)
- Family (adult(s) with children)
HOUSEHOLD INCOME
All personal information will be kept confidential and secure. You will be contacted by a YMCA representative to provide documents supporting your request for financial assistance. Your most recent tax return is the preferred form of documentation, but if you didn't file, you may choose another form. Select "YES" to provide a copy of your most recent tax return. Select "NO" to provide a copy of a CMA voucher, furlough/unemployment letter, or food assistance qualification.
Adjusted Gross Income*

Enter the amount from your last tax return, Form 1040.
Did you file a tax return this year?*
- Yes - You will need to provide a copy of the first two pages of the most recent 1040 for all adults in the household who will be included in YMCA membership and who have not been claimed as dependents on another adult member's taxes.
- No - You will need to provide a CMA voucher, furlough or unemployment letter, unemployment check, or food assistance qualification.
Upload Documents
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, a CMA letter, or your personal hardship letter. 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.
PROGRAM FINANCIAL ASSISTANCE
You may choose which programs for which you would like to apply for financial assistance. List children's full names under each program you wish to apply for. Children should be listed in the "Dependents" section above. Click the plus sign (+) to add additional children. If you are applying for membership assistance only, this section is not required.

AFTER SCHOOL CARE

First Name	Last Name

PARENTS MORNING OUT

First Name	Last Name

SUMMER CAMP

First Name	Last Name

How many weeks of Summer Day Camp are you requesting Financial Assistance for?

SWIM LESSONS

First Name	Last Name

YMCA CAMP CHA-LA-KEE

First Name	Last Name

YOUTH SPORTS

First Name	Last Name

CERTIFICATION OF INFORMATION
Applicant Signature*
Yes, I certify that this information is correct.
I certify that the information listed on this form is correct to the best of my knowledge. I understand that the Heart of the Valley YMCA is a nonprofit organization and that financial assistance is made possible through the generosity of donors and members. I understand that financial assistance will be awarded on a first-come, first-served basis. I agree to notify the Y if my financial situation improves, so that my financial assistance can be re-evaluated, thus providing more opportunities for others in our community. I understand that to maintain my financial assistance, the YMCA may, upon request, require updated financial information. I will be afforded at least 30 days to provide information when requested. Failure to do so may lead to the revocation of my financial assistance or termination of membership.

Please note that your approval rate is pending verification from our management team.

Financial Assistance Application Form

Financial Assistance Application Form

PRIMARY ADULT

SECOND ADULT

DEPENDENTS/ADDITIONAL MEMBERS

MEMBERSHIP FINANCIAL ASSISTANCE

HOUSEHOLD INCOME

PROGRAM FINANCIAL ASSISTANCE

CERTIFICATION OF INFORMATION