ARPA Form

1
How did you hear about the Y?
Friends
Billboard
Newspaper
Email
Social Media
Former Member
Medical Referral
Medical Insurance
2
Name* This field is required.List your name as it appears on your Driver's License
First Name
Last Name
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
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
5
Email* This field is required.
example@example.com
Confirm Email
6
Phone Number* This field is required.
Area Code
Phone Number
7
Physical Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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
8
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+
9
Additional Member of the Household #1
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
10
Additional Member of the Household #2
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
11
Additional Member of the Household #3* This field is required.
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
12
Additional Member of the Household #4
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
13
Additional Member of the Household #5
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
14
Additional Member of the Household #6
First and Last Name
Date of Birth (00/00/0000)
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?
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 or participating in programs?
15
Which programs are you interested in?* This field is required.Please select all programs you may be interested in. Some programs are location specific and not all programs are offered at all locations.
Before and After School Child Care
Summer Day Camp
Water Safety/Swim Lessons
Arts Classes
Gymnastics
Youth Sports Leagues
16
What is your annual household income?* This field is required.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.
17
Select all applicable documents you will attach to verify annual household income.We 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
SSI/Disability Award Letter/DSHS/TANF
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
18
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
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19
Tell Us MorePlease share any additional information not included on this form, if appropriate.
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20
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 ARPA Funded Programming. I understand that failure to comply with YMCA policies can and may result in immediate revocation of membership and program privileges.
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21
Today's Date* This field is required.
Date
Month
Day
Year
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