Financial Assistance Application

Financial Assistance Application

Thank you for applying for Financial Assistance to the Westport Weston Family YMCA. Please note that we review all applications very carefully, and due to the high volume of applications we receive while assistance cannot be guaranteed, we will work as best we can to assist you and your family.
Who Can Apply for Financial Assistance?
While anyone can apply at any time for financial assistance, because there are YMCA’s outside of our service area (Westport & Weston), it is recommended that residents residing in other locations please apply first at the YMCA which represents your area of service.

Financial Assistance can be utilized for:
Membership & Fee-Based programs excluding Personal Training & Private Swim Lessons

Where to Apply:
- Residents of Westport, Weston: Westport Weston Family YMCA
- Residents of Easton, Norwalk, and Wilton: Riverbrook YMCA in Wilton
- Residents of Fairfield, Southport: Fairfield YMCA
- Residents of Bridgeport: Fairfield or Stratford YMCA
- Residents of Darien: Darien YMCA
- Residents of New Canaan: New Canaan YMCA
- Residents of Stamford: Stamford YMCA
Please note that reciprocal privileges permit members from YMCA’s throughout the country to visit the Westport Weston Family YMCA 4x per month.

How to Complete the Application
- Please be sure to thoroughly complete this entire application.
- Please email copies of current tax returns & W2 forms to bmarazzi@westporty.org.
- Complete narrative (Section V) with detailed description on how the Westport Weston Family YMCA can help you, and why you prefer our YMCA.
- Incomplete applications will be returned.
- Contact Brian Marazzi at bmarazzi@westporty.org or (203) 226-8982 with any questions
Thank you.

Self/Parent/Guardian Information:
Date of application:*

MonthDayYear
Date
(Self/Mother/Guardian) Full Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Occupation
Company/Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Self/Father/Guardian) Full Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number

Area CodePhone Number
Occupation
Company/Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact's Email*
example@example.com
List All Dependents Names

Participant Information:
PLEASE NOTE: Some requests are subject to deadlines (check with the department for more information). Registration fees are not eligible for financial assistance.
Mark the department(s) for which you are applying for assistance (Check all that apply)*

Member ServicesSchool Age Child CareCamp MahackenoOther

Participant 1
Participant's Name
Department
Program

Participant 2
Participant's Name
Department
Program

Participant 3
Participant's Name
Department
Program

Participant 4
Participant's Name
Department
Program

Financial Information:

SECTION I: Income/$ per month (please list all sources including state and local assistance and other agencies or organizations)

	Mother/Guardian/Self	Father/Guardian/Self
1. Gross Wages
2. Social Security
3. Unemployment Compensation
4. Workers Comp
5. Pensions
6. Disability
7. Alimony and/or Child Support
8. Public Assistance* (list sources below)
9. Other (rents, family, etc)
10. Interests and/or Dividends
TOTAL

Public Assistance Sources

SECTION II: Liquid Assets/$ per month

	Mother/Guardian/Self	Father/Guardian/Self
1. Checking Accounts
2. Savings Accounts
3. Stocks/Bonds
4. Property other than Primary residence:
TOTAL

Please provide most recent official bank statements
SECTION III: Family Assets

A. Real Estate

Address 1
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Value (in $)
Year of Purchase
Equity (in $)
Mortgage (in $)

Address 2
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Value (in $)
Year of Purchase
Equity (in $)
Mortgage (in $)
B. Motor Vehicles

Motor Vehicle 1
Year
Make & Model
Market Value

Motor Vehicle 2
Year
Make & Model
Market Value
SECTION IV: Tax Returns

Submit copies of current year’s Federal tax return form 1040, 1040A or 1040 EZ and supporting W2 forms. If separated or divorced please include both parents’/guardian’s Federal tax returns and W2 forms if possible. If current tax return has not been filed yet, please attach a copy of your last year’s tax return in addition to copies of current year’s W2 forms and your filing of estimated liability for the current year.

Please email forms to bmarazzi@westporty.org directly after submitting this application.
SECTION V: Narrative

Please provide a narrative explaining your current situation and the benefit that will be received if financial assistance is provided. Address what services, if any, would be used in the event that financial aid is not provided; and as a result, attendance in our program would not be possible. Please include any additional information you feel would be helpful to us in making a decision regarding your application for scholarship.
Your Narrative:*

SECTION VI: The applicant certifies that the above statements are true and complete and authorizes verification by the Westport Weston Family Y.
Signature of Applicant(s)*

Clear
Date*

MonthDayYear
Date
Signature of Applicant(s)

Clear
Date

MonthDayYear
Date
Primary Contact's Email*
example@example.com
IF THERE IS ANY CHANGE IN YOUR STATUS UPON COMPLETION OF THIS APPLICATION, YOU ARE REQUIRED TO CONTACT US.

All scholarship decisions are made without regard to race, creed, color, religion, or national origin. Information will be kept confidential.

This award is good for one year. It is your responsibility to reapply each year.

Families applying for Camp Mahackeno must reapply each year regardless of prior financial assistance awards.

Please allow at least three weeks for processing.
Financial Assistance Application Checklist:

1) All five pages are complete.

2) Form is signed and dated by applicant(s).

3) Copy of current tax returns and W2 Form(s) are emailed to bmarazzi@westporty.org

4) Narrative is included.

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
Should be Empty:

Financial Assistance Application

Self/Parent/Guardian Information:

Participant Information:

Financial Information: