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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*
MM slash DD slash YYYY
Address*
Please list the name of an emergency contact
(area code) phone number
Are you age 65 or over?*
Are you Active Duty Military?*
Please select your branch:*

SECOND ADULT

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

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.

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. 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.
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, 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
     
    SUMMER DAY & HOLIDAY CAMP
    First Name
    Last Name
     
    GROUP SWIM LESSONS & YEAR-ROUND AND SUMMER SWIM TEAMS
    First Name
    Last Name
     
    YOUTH SPORTS
    First Name
    Last Name
     

    CERTIFICATION OF INFORMATION

    Applicant Signature*

    Heart of the Valley YMCA