YMCA Financial Assistance Program Application

NEW YMCA Cares - Financial Assistance Application
In these uncertain times, we don’t want anyone to be turned away from the YMCA and this program will help you and your family take part in everything the Y has to offer.
We believe the Y is here to make our community a better place for all.

Head of Household

Head of Household

Address
City
State/Province
Zip/Postal
mm/dd/yyyy
additional discounts may apply; we have several partnerships with various insurance carriers

What Are You Applying For?

Check all that apply

Household Resident Information

Please add all household residents information below.
mm/dd/yyyy
Relationship to Head of Household

Financial Information

Please total all household income for all persons above.

Monthly Amount
Monthly Amount
Monthly Amount
Monthly Amount
Monthly Amount
Monthly Amount
Monthly Amount
Monthly Amount

Proof of Income

Needs to be dropped off at your Branch Location at the Front Desk to the attention of the Branch Director


Statement Of Need

(In the space below, please describe the reason and need for financial assistance.) I am willing to share my YMCA Cares experience to help educate the community on the financial assistance program and how it has benefited me and/or my family. I understand that this is voluntary and my name as well as the names used in this statement will be changed and kept confidential. I am aware that the purpose of this statement is to assist the Y in their educational fundraising efforts.

* Required

To the best of my knowledge, all the information in this application is true and complete. I realize the Y’s financial resources are limited and therefore, I may be asked to seek additional funding from other sources. I will immediately notify the Y of any changes that might affect my financial status. I accept the responsibility to make scheduled payments on or before the due dates. I will contact the Y if I cannot make a payment on time. I realize that failure to make payments on time and/or to contact the Y regarding payments due, will result in the loss of any assistance granted. I also recognize that as a result of financial contributions made to the Y, my participation has been made possible. I agree to support the Y’s policies, program and staff.

Sending