YMCA of the Twin Tiers Financial Assistance Application

Financial Assistance Application

Please complete the form below to apply for Financial Assistance at the YMCA of the Twin Tiers.
COMMITTED TO OUR COMMUNITY

Assistance amounts are handled in a fair and consistent manner using a sliding scale. Every YMCA member receives the same membership benefits, regardless of whether or not they receive assistance. YMCA members can feel confident knowing that they are a part of an organization that cares greatly for the well-being of all people and is committed to youth development, healthy living, and social responsibility.
WHAT YOU NEED TO KNOW BEFORE APPLYING:

The YMCA of the Twin Tiers believes in providing membership and program services to all who desire to participate. The Financial Assistance program, supported in part through donations to the Annual Community Support Campaign, provides membership and program services to those in need within our available resources.
- Applications without income documentation will be denied.
- Please allow up to five (5) business days for application processing.
- All documentation will be shredded upon determination of Financial Assistance award.
- Financial Assistance reduces fees; it does not eliminate them.
- Financial Assistance will be granted on a 6-month or 12-month basis depending on the situation and must be renewed prior to the expiration date.
- Delinquent payments will result in revocation of Financial Assistance award.
- Membership fees are subject to change.
Application must be filled out completely. Please fill out completely and include all required paperwork.
Home branch applying for:*

Bradford YMCAOlean YMCAWellsville YMCA
I am applying for:*

MembershipChild Care/CampOther
Membership type applying for:*

Young AdultAdultAdult CoupleSingle Parent FamilyFamilySeniorSenior Couple
APPLICANT INFORMATION
Full Name*

First NameMiddle NameLast Name
Email Address*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Employer*
Employment Status (Full or Part Time)*
Hourly Wage ($)*
Annual Income ($)*
ALL PERSONS LIVING IN THE HOUSEHOLD

List All Persons Living In This Household*

	Full Name	Date of Birth
Adult
Adult
Child
Child
Child
Child
Child
Child
Other Dependent

SPOUSE OR OTHER WAGE EARNER
Full Name*

First NameMiddle NameLast Name
Employer*
Employment Status (Full or Part Time)*
Hourly Wage ($)*
Annual Income ($)*

TOTAL HOUSEHOLD MONTHLY INCOME*

	$______________
Household Wages
Worker's Comp
Food Stamps
Child Support
Social Security
Unemployment
All Other Income
TOTAL MONTHLY INCOME

SUBMIT THE FOLLOWING DOCUMENTATION FOR CONSIDERATION

1) 1040 Federal Tax Form for all incomes in household

OR

2) Two (2) Most recent pay stubs for all incomes in household or SSI/D statement of benefits

OR

3) Most recent bank statement

NOTE: Documentation MUST accompany application to be considered for assistance.
Browse Files
Upload Documentation Here: Cancelof
List any special circumstances that you feel should be taken into consideration during application review:*
What does joining the YMCA mean to you and/or your family?*
Signature of Application: I certify that the information supplied herein is true, accurate, and complete to the best of my knowledge and I grant the Y permission to verify information contained herein.*

Clear
Today's date*

MonthDayYear
Date
Should be Empty: