Y Experience Scholarship Application

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Is this a new application or are submitting for renewal?

New application

Renew existing scholarship

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Name* This field is required.

First Name

Last Name

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Date of Birth* This field is required.

Date

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Email* This field is required.

example@example.com

Confirm Email

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Phone Number* This field is required.

Area Code

Phone Number

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Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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What is your primary YMCA location?* This field is required.

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Number of additional persons living in this household* This field is required.

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Additional Member of the Household #1

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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Additional Member of the Household #2

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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Additional Member of the Household #3

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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Additional Member of the Household #4

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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Additional Member of the Household #5

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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Additional Member of the Household #6

First and Last Name

Date of Birth (00/00/0000)

Relationship to Applicant

Joining as a Y member

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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

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Federal taxes files: Select one document you will attach to demonstrate income level for each adult in the householdWe do not accept W-2s or bank statements for your security.

1040 Federal Tax Form(s) for All Adults in Household

SSI/Disability Award Letter/DSHS/TANF

Two 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

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Federal taxes not filed: Select one document you will attach to demonstrate income level for each adult in the householdWe do not accept W-2s or bank statements for your security.

Non-Filing Form

SSI/Disability Award Letter/DSHS/TANF

I-20 Form (International Students)

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Please upload document(s) noted above* This field is required.You may upload original files or photos of the documents.

Drag and drop files here

Select files to upload

Max. file size: 10.0MB

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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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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

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Today's Date* This field is required.

Date

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