Programs Financial Assistance Application First Name 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 Is this your first time applying or is this a renewal? New Renewal I am requesting funds for myself. - Select -YesNo First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified Best Day/Time to Call Please select which program(s) you are requesting funds for at this time Sports Aquatics & Swim Lessons Wellness & Fitness Community Health Classes Total Household Members Number of adults/kids living in residence Wages and Tips Unemployment (if applicable) Social Security/Disability (if applicable) Food Stamps/WIC (if applicable) Child/Spousal Support (if applicable) Worker's Compensation (if applicable) Rental/Utility Assistance (if applicable) Other (if applicable) 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 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.
