Financial Assistance Application

Personal Info

Thank you for filling out the fields below! Please note that you must claim the child you are requesting Financial Assistance for on your taxes and pay for their child care fees.
Total Number of People in Household (Please include yourself)
Your Full Name
Your Birth Date

MonthDayYear
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address Line 1

Street Address Line 2

CityState

Zip CodeCountry
Secondary Adult Applicant (if applicable)

First NameLast Name
Secondary Adult Birth Date (if applicable)

MonthDayYear

Please tell us briefly how the Financial Assistance would benefit your family.

Income & Supplemental Materials

All applicants must submit proof of income below. We accept the first 5 pages of your most recent federal tax return AND 3 consecutive paystubs from the last three pay periods. If you have a Government Assistance Statement, or an SSI / SSDI Disbursement Voucher, please submit those materials as well. If you are self employed, we need a copy of your business license and three consecutive bank statements. Your application will not be processed without the proper proof of income AND most recent tax return.
Total Household Gross Monthly Income (before taxes and deductions)
This includes your spouse / partner's income and all assistance.
Upload proof of income (paystubs etc) and first 5 pages of your tax return. Applications without legible documentation will not be processed.

Cancelof

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. I will be responsible for full fee until my application is processed. The YMCA does not back date assistance. The YMCA believes a strong sense of ownership and pride is developed if financial assistance recipients contribute to the cost of their involvement. Applicants are asked to pay a portion of their program fees. All rates and fees are to be kept confidential, as they are specific to individual circumstances. I agree to inform the Y Kids Business Office of any change in my financial status.
Only complete appications will be processed in a timely manner. If your application is not complete, you will be requested to resubmit an application with all your documents. You will receive an email from our business office informing you of your approval status once your application has been processed.

Currently Enrolled:

If your application is approved, You will receive an approval email. We will make the update to your fees for the next draft and through the duration of your current contract if you are already enrolled. If you are not approved and wish to reamin in the program, there is no further action required. If you wish to cancel your enrollment you will need to provide cancellation notice via email based on the YMCA cancellation policy.

Not Yet Enrolled:

Please reach out directly to your child care site director. They can assist with enrollment. Once you have worked with your site director to ernoll, please email our busniess office at kmartinez@ymcaeastbay.org, we will then apply the assistnace. Pleae provide a copy of your approval email with your request. Financial Assistance will not be applied without proof of approval.

Billing with Financial Assistance:

The YMCA requires the person approved, to pay for the monthly child care fees.
Signature of Primary Applicant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: