Financial Assistance Form

FINANCIAL ASSISTANCE Application

To apply for financial assistance, please complete all questions.
Your preferred branch: *
For information about the branches of River Crossing YMCA, visit our webpage here
Applicant Information

Person requesting assistance (if minor, use Parent or Guardian's name)
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Please enter a numeral (example: 69)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Daytime number*
To contact you and/or leave a message
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.

Are you applying for Child Care assistance?*

Yes (see below, apply for ELRC or Norwescap first)No (skip to next section)
Are you applying for Summer Camp assistance?*

Yes (see below, apply for ELRC or Norwescap first)No (skip to next section)
If you selected YES, please read below:

Before financial assistance is granted for our child care centers, we need to verify if your family would qualify for funding through Early Learning Resource Center (ELRC) or New Jersey Cares for Kids (NJCK Norwescap). These agencies are subsidized childcare programs that help low-income families pay their childcare fees. The state and federal governments fund this program, which is managed by ELRC and Norwescap. Should you seem eligible for ELRC or Norwescap, it is our policy that you apply for their subsidy first before we can process your application for financial assistance for child care or summer camp.
1. Please review their guidelines.
  - PA APPLICANTS - ELRC
  - NJ APPLICANTS - NORWESCAP
2. Determine your eligibility.
  - If you qualify, please submit an application to them.
  - Provide the Y with a copy of your Eligibility Letter you will receive from ELRC and Norwescap after they process your application.

Sources of income
Please list all sources of MONTHLY income. Support documentation is required before processing can start.
Gross Wages/Salary
ATTACH THREE, MOST RECENT AND CONSECUTIVE PAYSTUBS and ATTACH CURRENT FEDERAL INCOME TAX RETURN:-Form 1040 with Letter Schedules if applicable (Not W-2)
Gross Wages/Salary
Optional additional comments or clarifying information
Child Support/Alimony
ATTACH CURRENT CHILD SUPPORT/ALIMONY DOCUMENTATION
Child Support/Alimony
Optional additional comments or clarifying information
Disability/Social Security
ATTACH CURRENT SOCIAL SECURITY, OR DISABILITY STATEMENT
Disability/Social Security
Optional additional comments or clarifying information
Unemployment Compensation
ATTACH UNEMPLOYMENT DETERMINATION DOCUMENT
Unemployment Compensation
Optional additional comments or clarifying information
Other
ATTACH SUPPORTING DOCUMENTATION
Other Income
Optional additional comments or clarifying information
=TOTAL GROSS*
Upload support Documentation

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Major Monthly Expenses

Please list the amounts for the following major, monthly expenses.
Rent or Mortgage
Child Support/Alimony
Medical Bills
(NOT INCLUDING INSURANCE OR CO-PAYS)
Student Loans
ATTACH MONTHLY PAYMENT AND BALANCE
Other
TOTAL MONTHLY EXPENSES*
Upload Supporting Documentation

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Please make sure that you have completed all sections of this form. Supporting documentation is required to process your application for all sources of household income.
- If you need to send additional supporting documentation, please email it to financialassistance@ymcarivercrossing.org, or mail it to Catherine Refice, River Crossing YMCA, 2500 Lower State Road, Doylestown, PA 18901.
- You will be notified via email if additional information is needed.
- Allow at least three (3) weeks for processing once all supporting documentation is received.
- You will receive a letter by mail notifying you of your qualifying status.
- Assistance will be granted for one year.
Registered Sex Offender Statement
As a youth serving organization, River Crossing YMCA conducts regular sex offender screenings against the national database using Raptor Technologies. Raptor Technologies, provides the capability to search the national database of known sex offenders. Our Y will scan the entire database monthly for registered sex offenders, and daily for new members, visitors, guests and as part of our financial assistance application process. All visitors or guests must provide a valid state or government issued photo ID to be scanned through our Raptor Software. Those verified as known sex offenders will receive notification and membership will be terminated immediately. By submitting this application, I acknowledge and accept this policy.
Signature*

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Date of Signature*

MonthDayYear
Date
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FINANCIAL ASSISTANCE Application

Applicant Information

FAMILY INFORMATION

Household Information

Household Member #1 (yourself)

Sources of income

Major Monthly Expenses