Financial Assistance Application

Financial Assistance Application

The YMCA of the East Bay strives to provide financial assistance to youth and adults, based on individual needs and circumstances. This is made possible through donations, and funds are distributed on a first come, first serve basis. Thank you for taking a few minutes to fill out our application. We will be in touch about your application status as soon as possible!
Do you have an active membership at the YMCA of the East Bay?*

Yes, my membership is active at a branch of the YMCA of the East BayNo, but I was a former member at a branch of the YMCA of the East BayNo, I have never had a membership to the YMCA of the East Bay
Branch*

Berkeley YMCAOakland YMCAPleasant Hill YMCAAlbany YMCA

Dependents in Household

Please list the name, DOB, and relationship of all dependents in your household not listed above. Applicants with no dependents may move on to the next section.
1. Full Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to you
2. Full Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to you
3. Full Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to you
4. Full Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to you

Please tell us briefly how the Financial Assistance package would benefit you and/or your family.*

Income & Supplemental Materials

All applicants must submit proof of income below. We accept the first 2 pages of your most recent federal tax return (1040, 1040A, 1040EZ). If you have a Government Assistance Statement, or an SSI / SSDI Disbursement Voucher, please submit those materials as well.
Materials Required for Full-Time College Students:

Students ages 18-26 will automatically receive the Young Adult rate and need not apply. Full-time college students age 27+ should use the submission field below to provide your course schedule showing enrollment in the current term and a photocopy of your school ID card in addition to income verification documents listed above.
Total Household Gross Monthly Income*
This includes your spouse / partner's income and all assistance.
Upload all proof of income or proof of college enrollment files here! *

All applicants must submit proof of income. We are looking for the first 2 pages of your most recent federal tax return (1040, 1040A, 1040EZ) along with any applicable Government assistance statements, or SSI / SSDI disbursement vouchers. Bank statements, W-2s, and 10-99's are NOT acceptable as proof of income.
Cancelof

Are you interested in applying for Financial Assistance for YMCA youth programs for children ages 12 and under? (Swim Lessons, Youth Basketball, etc.)*

YesNo

Youth Program Financial Assistance

This application is for youth swim lessons and youth programs in the YMCA of the East Bay. Child Care, Summer Day Camp, and Camp Loma Mar may require separate applications.
I am applying for Youth Program Financial Assistance for:*

Berkeley YMCAOakland YMCAPleasant Hill YMCA
Parent/Guardian Name *

First NameLast Name
Date of Birth *

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Signature & Acknowledgement

I understand that the completion of this application does not guarantee that I will receive Financial Assistance from the YMCA of the East Bay. I certify that all of the above information is accurate and I authorize the YMCA of the East Bay to verify the information provided.
Signature of Primary Applicant or Parent / Guardian of Applicant*

Clear
Date*

MonthDayYear
Date
Signature of Secondary Adult Applicant (if applicable)

Clear
Date

MonthDayYear
Date
Should be Empty:

Personal Info