Financial Assistance Application

Financial Assistance Application

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.


    Enter information for the Primary Adult on your membership account.
  • MM slash DD slash YYYY
  • Please list the name of an emergency contact
  • (area code) phone number

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

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

    Choose the type of membership for which you are applying.
  • 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.

    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.
  • Drop files here or
    Accepted file types: pdf, jpg, png, doc, Max. file size: 200 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.

      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.
    • First NameLast Name 
    • First NameLast Name 
    • First NameLast Name 
    • First NameLast Name 
    • First NameLast Name 
    • First NameLast Name 

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    Heart of the Valley YMCA