Child Care FA | YMCA Western North Carolina

Parent/Guardian First Name

Parent/Guardian Last Name

Primary Phone

Primary Email

Program

Afterschool

Summer Camp

Program Site

Child 1 Full Name

Child 1 DOB

Child 1 Grade

Child 2 Full Name

Child 2 DOB

Child 2 Grade

Child 3 Full Name

Child 3 DOB

Child 3 Grade

Have you applied for county vouchers?

Outcome of phone call and person spoken to:

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 a full-time student?

Are you a grandparent or older relative with guardianship?

Are you 55 or older?

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 Financial Assistance, I understand that my portion of the child care program cost must be paid on time and my account must be kept current. Failure to comply with the payment polices outlined in the program handbook may jeopardize future financial assistance.

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)