Financial Assistance | Childcare | Form Submit

Applicants for YMCA childcare financial assistance must be working a minimum of 30 hours per week or be a full-time student.

The YMCA of Western North Carolina is committed to helping individuals reach their fullest potential through programs that develop a healthy spirit, mind, and body. We serve people of all ages, abilities, and incomes. It is our belief that no one should be denied our services due to an inability to pay. Our Y-Access program offers a sliding scale of payments designed to accommodate the situation of any individual or family. Funding for this program is made possible through the generous support of our donors to our annual campaign.

Parent/Guardian First Name

Parent/Guardian Last Name

Primary Phone

Primary Email

Program

Afterschool

Summer day camp

Program Site

Child 1 First Name

Child 1 Age

Child 1 Grade

Child 2 First Name

Child 2 Age

Child 2 Grade

Child 3 First Name

Child 3 Age

Child 3 Grade

Number of household members

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.
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.

Paycheck stub 2

One file only.
128 MB limit.
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Paycheck stub 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.

Tax return

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.

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.

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Childcare Financial Assistance Application