Family YMCA of Northwest Illinois Scholarship Application

the
YMCA
WE ARE MORE THAN JUST A GYM
MEMBERSHIP FOR ALL
Membership & Program Support Application

Thank you for your interest in YMCA financial assistance. We offer financial assistance to individuals and families who are not able to pay full fees for Y memberships and/or programs. Please bring all the following information to the YMCA Welcome Center to apply for financial assistance.

Completed and signed financial assistance application along with a separate sheet indicating why you are applying for financial assistance.

A copy of your most recent federal income tax return (not W2 If you do not file federal

income taxes, call 1-800-TAX-FORM (1-800-829-3676) or go to www.irs.gov and fill out

Form 4506-T to request a Verification of Non-filing letter (required

Two most recent paycheck stubs or letters from your employer verifying your employment and stating your annual salary. If you are unemployed, draw social security or a full-time student; please provide a summary of your unemployment benefits, SSI paperwork, financial aid benefits, and a dated student schedule.

Please mark out all social security numbers, tax ID numbers, and credit card numbers be- fore submitting any paperwork. Bring all completed forms and necessary paperwork to the YMCA Welcome Desk. Be sure to include all of the needed items and paperwork, as missing documentation will slow down the application evaluation process. You will receive all letters within 30 days regarding your qualifications and the next steps.

We look forward to serving you!

Sincerely,
Rich Haight
CEO
Family YMCA of NW IL
PLEASE NOTE
Support from our Annual Campaign Fund Reduces membership and program fees; It does not eliminate them.

All support will be granted for 12 months.

Membership and program fees are subject to change upon annual review.
2998 W. Pearl City Rd. Freeport, IL 61032

Phone: 815-235-9622 Fax: 815-232-2197

Family YMCA of Northwest Illinois Financial Assistance Application
The YMCA strives to make out programs and membership available to all who will benefit from them, regardless of their ability to pay. All financial assistance is granted on a sliding scale based on income and need. All information is kept confidential.

New ApplicationRenewal
Date

MaleFemale
Date

MonthDayYear
Date
Name
Birth Date

MonthDayYear
Date
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Phone
Mobile
Email
example@example.com
Select the type of membership for which you are applying

FAMILY/HOUSEHOLD Two adults and dependent children under the age of 24 living in the same household.SINGLE PARENT FAMILY: One adult and dependent children under the age of 24 living in the same household.STUDENT: 13 - 18 years old; college full time (12 credit hours or more), 23 years of age and under and not employed full time.Adult: : Adults 18 years and older, no longer in high school or full time college student.RETIREE: 60+ years, not employed full timeRETIRED COUPLE: One spouse 60 and over,Youth: 12 years and under (may be infant to receive member rate for classes.
Spouse and Dependents Living at Home

Tax Forms must reflect those that are listed below (they must be listed as dependents on your tax form). For students over 18 years, include a current copy of their class schedule (must be 12+ credit hours to qualify).
Name
Employer/School
Birthdate

MonthDayYear
Date
Gender
Relationship
Name
Employer/School
Date

MonthDayYear
Date
Gender
Relationship
Name
Employer/School
Date

MonthDayYear
Date
Gender
Relationship
Programs Please specify any programs for which you are requesting assistance.

Youth Sports (basketball, indoor soccer, outdoor soccer, flag football, volleyball)Aquatics (youth group swim lessons)Bluefins SwimteamGroup Fitness Classes yoga, group cycling, aquarobics, etc
Please itemize your gross annual household income. Documentation is required.
Your Income: Salary, wages and tips
Your Income: Unemployment Compensation
Your Income: Social Security Compensation
Your Income: Child Support
Your Income: TANF
Your Income: Food Stamps
Your Income: 401 (K) Retirement
Your Income: Allimony
Your Income: School Loan Income
Your Income: Other
Your Income: Total Annual Income
Spouses Income: (If Applicable) Salary, wages and tips
Spouses Income: (If Applicable) Total Annual Income
Other Income
Other Income: Total Annual Other Income
Submit your completed Financial Assistance Application with the following:

1. Current year's Federal Tax Return (Form 1040 pages 1 and 2 only; or 1040EZ

2. Copies of your last two paycheck stubs OR a letter from your employer stating your annual salary

3. Copies of any supporting documentation listed in the above annual salary line items.

4. A separate sheet indicating why you are applying for financial assistance.
I do not file a Federal Tax Return based on federal government income guidelines. Must include verification of Non-filing letter.
Applications received without the above documentation attached will be returned unprocessed.

I certify that this information is true and complete to the best of my knowledge. I grant permission to the YMCA to verify this information. I agree to notify the YMCA if my financial status should change.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Should be Empty:

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the

YMCA

WE ARE MORE THAN JUST A GYM

MEMBERSHIP FOR ALL

PLEASE NOTE