Scholarship Application

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Scholarship Application

For fastest processing visit your local YMCA Center after submitting this application and let them know you applied for a scholarship online. Please share income and benefit documentation for everyone in the household who shares in household expenses. Income verification can be two months' worth of paystubs, 3 months of profit-loss from self-employment, or a completed and filed tax return from last year. Benefit documentation can include but is not limited to award letters for; SNAP, TANF, SSI, Disability, Military Retirement and/or Disability, Child Support and Unemployment.

22Questions

Language

English (US)
Spanish (Latin America)

1
Is this a new application or are submitting for renewal?Please note, processing time for online submissions will vary and can take over a month. For fastest processing please visit your local YMCA Center in person after submitting this online application and let them know you submitted this application.
New application
Renew existing scholarship
2
How did you hear about the Y?* This field is required.
Friends
Billboard
Newspaper
Email
Social Media
Former Member
Medical Referral
Medical insurance
3
Name* This field is required.List your name as it appears on your Driver's License
First Name
Last Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
What race do you identify with?* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
6
Email* This field is required.
example@example.com
Confirm Email
7
Phone Number* This field is required.
Area Code
Phone Number
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
What is your primary YMCA location?* This field is required.
Bremerton Family YMCA
Gordon Family YMCA
Haselwood Family YMCA
Lakewood Family YMCA
Mel Korum Family YMCA
Morgan Family YMCA
Tacoma Center YMCA
Tom Taylor Family YMCA
University Y Student Center
10
Number of additional persons living in this household* This field is required.Total number of additional individuals in your household.
0
1
2
3
4
5
6+
11
Additional Member of the Household #1* This field is required.
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
12
Additional Member of the Household #2
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
13
Additional Member of the Household #3
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
14
Additional Member of the Household #4
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
15
Additional Member of the Household #5
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
16
Additional Member of the Household #6
First and Last Name
Date of Birth (00/00/0000)
Please Select
Please Select
Spouse/Partner
Child/Child in Foster Care
Dependent Adult
Other
Relationship to Applicant
Please Select
Please Select
Yes
No
Interested in joining as a Y member?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Some other
Two or more races
What race do you identify with?
17
Did you file for federal taxes for the last year and/or received social security?* This field is required.This helps us determine which documents to request for income verification.
YESNO
18
What is your annual household income?Total annual income for your household. Please include income from all contributing adults and supplemental income. In the next section you will be asked to upload documentation to verify your household income.
19
Select documents you will attach to demonstrate income level for each adult in the householdWe do not accept W-2s or bank statements for your security. Select applicable documents for all contributing adults in the household.
1040 Federal Tax Form(s) for All Adults in Household
Income Benefits: SSI/Disability Award Letter/TANF/etc.
Two Most Recent Consecutive Months Pay Stubs
Pension or Other Retirement Income
Leave and Earning Statement, including Base Housing Alliance (BHA)
Self Employed – Current Profit and Loss Statement
Unemployment
Non-Filing Form
I-20 Form (International Students)
Other
20
Federal taxes not filed: Select documents you will attach to demonstrate income level for each adult in the householdWe do not accept W-2s or bank statements for your security. Please submit entire document.
Non-Filing Form
Income Benefits: SSI/Disability Award Letter/TANF etc.
I-20 Form (International Students)
21
Please upload document(s) noted above* This field is required.You may upload original files or photos of the documents. Be sure to upload all applicable income documents for all contributing adults in the household, if all documents are not uploaded we will be unable to process your application.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
22
Tell Us MorePlease share any additional information not included on this form, if appropriate. Also, tell us how a YMCA membership will benefit you and/or your family.
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Large
Normal
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Ok
Ok
23
Signature* This field is required.My signature, below, certifies I have read and understand the following: The information supplied herein is true, accurate, and complete to the best of my knowledge. I am aware it is my responsibility to notify the YMCA in writing of any changes to the information supplied in this application, such as income, address, and/or other matters that might affect my eligibility for a Y Experience Scholarship. I understand that failure to comply with YMCA policies can and may result in immediate revocation of membership and program privileges. I am also aware that the YMCA reviews my application bi-annually, and failure to submit review paperwork will result in my membership fees being adjusted to the current full membership rate.
Clear
24
Today's Date* This field is required.
Date
Month
Day
Year
Should be Empty:

Scholarship Application

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