Membership Financial Assistance Enter your information to see if you qualify! Primary Member First Name Primary Member Last Name Primary Phone Primary Email Birthdate Residence Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Are you new to Y-Access or is this a renewal? New Renewal Best Day/Time to Call Membership (Please Check One) Teen/Youth One individual, age 8-17 Young Adult One individual, age 18-26 Adult One individual, age 27-64 Senior Adult One individual, age 65+ One Adult Household One individual, age 18+, any dependents 21 and under Two Adult Household Two individuals, age 18+, no dependents Household Two individuals, age 18+, any dependents 21 and under Senior Household Two individuals, both 65+, no dependents Programs (if applicable) Sports Aquatics Community Health Program Adult Program Total Household Members Number of adults/kids living in residence Unemployment Social Security/Disability Wages and Tips Food Stamps/WIC Child/Spousal Support Worker's Compensation Rental/Utility Assistance Other Loans, Grants, Gifts, etc. Income Source 1 One file only.128 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. Income Source 2 One file only.128 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. Income Source 3 One file only.128 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. Do you receive "in-kind support" such as a family member or friend paying for expenses? If so, please explain. How much can you afford to pay for your membership/program? Tell us more about your situation and how the Y can help. Honesty Agreement I certify that the information included in this application is true and complete to the best of my knowledge, and that I do not have additional income not represented on this form. I agree to provide additional information to support this information, if requested. I understand my Y-Access assistance is based on need. In the event that my situation changes, I will contact the YMCA immediately. I understand that if I falsify this information, I will not be eligible for assistance now and/or in the future. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
