OPEN DOORS Financial Assistance Application Form

OPEN DOORS

FINANCIAL ASSISTANCE APPLICATION
APPLICATION TYPE:
This application is for*

Applicant onlyEveryone in the household as listed below, including the applicantSpecific person(s)
If you selected specific person(s), list name(s):
The scholarship is towards (check all that apply)*

MembershipAfter School Program (if this is checked, indicate which school below)Youth sports (soccer, t-ball, swim lessons)CampCommunity health program (Livestrong, Parkinson's programs, Diabetes Prevention, Exercise is Medicine, Blood Pressure Self-Monitoring)
If you selected After School Program, please indicate the name of the school:
Takes place at all SDOC elementary schools except Tamassee Salem.

APPLICANT INFORMATION:
Applicant Name*

First NameLast Name
Male / Female*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Applicant's marital status?*

SingleMarriedDivorced/Separated/Widowed
Total number of ADULTS OVER 18 in the household*

ALL PERSONS LIVING IN THE HOUSEHOLD (INCLUDING THE APPLICANT):
Total number of people living in the household, INCLUDING the applicant*

List ALL residents of the household, regardless of whether the scholarship applies to them.

	First & Last Name	D.O.B. (M/D/Y)	Age	Gender (M/F)
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6

	Monthly gross $ amount
Wages, Salaries, Tips (Gross)
Unemployment
Social security
Child support
Aid to dependent children
Food stamps
401K/Retirement funds
Alimony
TOTAL MONTHLY GROSS INCOME (required):

	Monthly $ amount
Rent/Mortgage
Utilities
Food/Clothing
Medical
Phone
Car/insurance
Child support
Alimony
Other
TOTAL MONTHLY EXPENSES (required):

Please describe any special circumstances that should be taken into consideration during the review of this application (e.g medical bills, unemployment)

Please ensure that you UPLOAD ALL DOCUMENTS before submitting the form. Incomplete submissions may lead to delays in processing.
Supporting documents:

Cancelof

OPEN DOORS FINANCIAL ASSISTANCE APPLICATION AGREEMENT
The Foothills Area YMCA is a non-profit, charitable organization open to all people regardless of age, race, sex, religion, or ability to pay. The Foothills Area YMCA will not deny services to anyone because of inability to pay. Open Doors will be granted based upon available resources to anyone who can demonstrate a verifiable need through recognized proof of income. Valid proof of income will include but are not limited to the last tax return, your last paycheck stubs, and/or your most recent W2 forms. Copies of all sources of income are due before the membership can be started. Additionally, proof of all sources of income is due prior to scholarships being awarded for all programs such as CAMP, Afterschool Care, swim lessons, etc.

By my signature,
1. I certify the information provided to be true. I understand that if any information is found to be false, my assistance may be subject to termination.
2. I understand I will be asked to pay a portion of the fees through a monetary commitment and that failure to complete my financial commitment will prohibit me from applying again until those fees are paid. All fees must be paid with a payment method kept on file (credit card, debit card, bank account) for automatic payment of membership fees.
3. If my financial circumstances improve or reach a level where I no longer require assistance, I agree to notify the Y so that others in need may avail themselves of assis-tance.
4. I understand that assistance is for a specific period of time not to exceed 12 months for Membership and 9 months for After School. I understand that I must renew my financial assistance application prior to the end of the assistance period or my rate will automatically return to the full amount unless I terminate said membership.
Applicant Signature

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Please allow up to 10 business days for applications to be processed.

FOOTHILLS AREA YMCA, Cottingham Campus, 370 Memorial Drive, Seneca, SC 29672

864-571-9622 financialassistance@faymca.org
Please ensure that you UPLOAD ALL DOCUMENTS before submitting the form. Incomplete submissions may lead to delays in processing.
Should be Empty:

OPEN DOORS

APPLICATION TYPE:

APPLICANT INFORMATION:

ALL PERSONS LIVING IN THE HOUSEHOLD (INCLUDING THE APPLICANT):

FINANCIAL INFORMATION:

OPEN DOORS FINANCIAL ASSISTANCE APPLICATION AGREEMENT