YMCA of Upper Palmetto Financial Assistance

APPLICATION INFORMATION
Are you a current YMCA of Upper Palmetto Member?*

YesNo

YMCA of Upper Palmetto Primary Member Information
Name*

First NameLast Name
Gender*

MaleFemale
Date*

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

PRIMARY ADULT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Is there a second adult living in the same household?
Second Adult Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
DEPENDENT INFORMATION

Please list all the dependent children in the household. Tax forms must reflect those you list below. Dependents are (a) under age 19 at the end of the year and younger than you (or your spouse, if filing jointly), (b) under age 24 at the end of the year, a full-time student, and younger than you (or your spouse, if filing jointly), or (c) any age if permanently and totally disabled.
Do you have children?
Child Full Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Do you need to add another child?
Child Full Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Do you need to add another child?
Child Full Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Do you need to add another child?
Child Full Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Do you need to add another child?
Child Full Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Gender
Race
We are an Equal Opportunity Provider. Racial information is sometimes needed for grants and state funding*
Do you need to add another child?
Please list additional dependents along with date of birth, gender and race.

	Participant(s) Name
Basketball
Flag Football
Karate
Soccer
Group Swim Lessons

	Participant(s) Name
Group Swim Lessons

	Participant(s) Name
Group Swim Lessons

	Participant(s) Name
Group Swim Lessons

	Participant(s) Name
Basketball
Cheerleading
Gra-Y Football
Indoor Soccer
Group Swim Lessons

	Participant(s) Name
Group Swim Lessons

	Participant(s) Name
Basketball
Cheerleading
Flag Football
Sports Academy
Soccer
Group Swim Lessons

	Participant(s) Name
Soccer

YOUR STORY

Please share your reasons for applying for YMCA financial assistance. Please include any and all relevant details about recent life changes or anything you deem important. For example, a recent separation, job loss, or caring for an elderly parent.
Please Share Your Story
Our financial assistance program is funded by donations. We often share stories of individuals or families our programs have helped. May we use your story?
TAX RETURNS
Please submit your most recent federal tax returns (Form 1040 pages 1 and 2 only, or 1040 EZ).

If you do not file federal income taxes, please call 1-800-TAX-FORM (1-800-829-1040) for verification of non-filing or go to IRS.gov for other information.

If you are unemployed, draw social security, or a full-time student, please provide a summary of your unemployment benefits, SSI paperwork, or financial aid benefits and student schedules.

Make sure you have marked over personal data information such as social security numbers.
Tax Returns OR Verification of Non-filing *

Cancelof
Other Supporting Documents

Cancelof
I certify that all information provided is true and complete to the best of my knowledge. I grant permission to the YMCA to verify this information. I agree to notify the YMCA if my financial status should change.
Should be Empty:

APPLICATION INFORMATION

YMCA of Upper Palmetto Primary Member Information

PRIMARY ADULT INFORMATION

DEPENDENT INFORMATION

YOUR STORY

TAX RETURNS