Application for Financial Assistance
The Mt. Sterling Community Center YMCA scholarship assistance program is made possible through contributions from the Annual Campaign. Those not able to pay the full fee for memberships or programs may be awarded partial financial assistance based on their ability to pay. The YMCA believes a strong sense of ownership and pride is developed if the financial assistance recipient has contributed to the cost of their YMCA involvement. Therefore, applicants will be asked to pay a portion of the membership and program fee. Please provide the information requested on this form and attach the necessary documents (photocopies only) listed.
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
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Financial Information
Employer
*
Put N/A if unemployed
Length of Employment
*
Put N/A if unemployed
Application for financial assistance is to be best used for (mark all that apply)
*
Family Membership
Adult Membership
Programs/Classes
Sports leagues
Summer Day Camp
After School Program
Are you a single parent household?
*
Yes
No
Applicant's monthly OR annual gross income (please indicate if monthly or annual)
*
Spouse's monthly OR annual gross income (please indicate if monthly or annual)
Other household income
Please list any extenuating circumstances that are severely limited your income at this time.
*
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Family Information
If applicable
Spouse Information
Child 1 Information
Child 2 Information
Child 3 Information
Child 4 Information
Child 5 Information
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Personal References
Reference 1
*
Reference 2
*
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Documentation and Agreement
Along with the completed application, please provide the following:
Picture ID - preferably a driver's license
Proof of income received by all individuals in the household (examples: social security disability, child support, alimony, housing subsidy, two current consecutive pay stubs or copies of unemployment payments, state assistance)
Copy of your most current income tax return
Please upload supporting documents or turn them into the YMCA Welcome Desk - Attn: Jeff Summers
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By signing below, I certify that all information provided is correct to the best of my knowledge and may be verified by the Mt. Sterling Community Center YMCA. I understand that providing false information will make me ineligible for participation in all YMCA programs and facilities. I understand that the decision to grant a reduction of fees is at the sole discretion of the YMCA and its officials. I understand that if I fail to abide by the payment schedule agreed upon, membership privileges may be revoked and I may be ineligible for future fee reductions. I also understand that I must apply annually by the renewal date for further assistance.
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