Camp Watia FA | YMCA Western North Carolina

Parent/Guardian First Name

Parent/Guardian Last Name

Primary Phone

Primary Email

Child 1 Full Name

Child 1 DOB

Child 1 Age

Child 1 Sex

Child 1 Race

Child 1 Grade

Child 2 Full Name

Child 2 DOB

Child 2 Age

Child 2 Sex

Child 2 Race

Child 2 Grade

Child 3 Full Name

Child 3 DOB

Child 3 Age

Child 3 Sex

Child 3 Race

Child 3 Grade

First Choice of Session

Second Choice of Session

Third Choice of Session

Monthly Income

Annual Income

AFCD per month (if applicable)

Food Stamps per month (if applicable)

Child Support per month (if applicable)

Pensions per month (if applicable)

Other income per month (if applicable)

How many hours per week do you work?

How many hours per week does your spouse/partner work?

Paycheck Stub 1

One file only.
2 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Paycheck Stub 2

Paycheck Stub 3

Tax Return

How much could you possibly pay per week?

Are you a single parent?

Are you or your camper a member of the EBCI?

Are you a full-time student?

Please list any extenuating circumstances for us to consider when reviewing your application.

If your child has previously received Financial Assistance, how do you feel the program has helped your child?

Signature

I acknowledge that if I am offered, and accept YMCA Financial Assistance, I understand that my portion of camp tuition must be paid on time and my account must be kept current. Failure to comply with the payment policies may jeopardize future financial assistance.

Sessions Preferred

Financial Information

*REQUIRED: Copies of your last three paycheck stubs for you and your spouse (if applicable).

*REQUIRED: Copy of your current tax return (1st page only with your dependent listed and your AGI)