Membership Type (please choose 1)
*
Youth
Young Adult
Adult
Family
Couple
Primary Applicant Information:
*
First Name
Last Name
Birthdate
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
*If Under 18 Please provide Parent or Legal Guardian Name
*
Address
*
City
*
State
*
Zip Code
*
Email Address
*
example@example.com
Phone Number
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
How many people are living in your household?
*
Please provide all names and birthdates below (regardless the membership type you are applying for)
Spouses Name
Spouses Birthdate
-
Month
-
Day
Year
Date
Spouses Gender
Male
Female
Child 1 Name
Child 1 Birthdate
-
Month
-
Day
Year
Date
Child 1 Gender
Male
Female
Child 2 Name
Child 2 Birthdate
-
Month
-
Day
Year
Date
Child 2 Gender
Male
Female
Child 3 Name
Child 3 Birthdate
-
Month
-
Day
Year
Date
Child 3 Gender
Male
Female
Child 4 Name
Child 4 Birthdate
-
Month
-
Day
Year
Date
Child 4 Gender
Male
Female
Please provide your monthly gross income for every applicable item below:
Head of household gross wages, salary & tips
*
Spouses gross wages, salary & tips
*
Unemployment Compensation
*
Social Security/Disability
*
Child Support
*
Government Assistance/Housing Allowance
*
Food Stamps
*
Other Income (Alimony, Interest, Dividends, etc)
*
Total Monthly Income:
*
Upload all corresponding documentation in the box below. **Bank Statements and W-2's not accepted. Please provide at least 2 months of paystubs**
*
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If $0 income you must provide a letter stating how you survive financially and how you will pay for the scholarship:
Why do you need financial assistance? Please be specific and state why a membership to the YMCA will benefit your household.
What is your Individual fitness goal?
If applying for a family membership, what is your goal as a family?
I certify that the above information is true and complete to the best of my knowledge and that I do not have additional income not represented above. I understand that if I falsify any of the above information I will not be eligible for assistance now and/or in the future.
Date
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Month
-
Day
Year
Date
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