Active Generations Reduced Rate Membership Application
Thank you for your interest in the Income-Eligible Reduced Membership Program at Active Generations. Our goal is to ensure all individuals have access to our services and programs, regardless of financial circumstances. Please complete this form and submit it with the required documentation. All information will be kept confidential.
Section 1: Personal Information
1. Name:
*
First Name
Last Name
2. Date of Birth:
*
-
Month
-
Day
Year
3. Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
5. Email:
example@example.com
Section 2: Household Information
1. Total Number of People in Your Household:
*
2. Please list the name and date of birth of each member of the household:
*
3. Annual Household Income:
*
$0 - $10,000
$10,001 - $20,000
$20,001 - $30,000
$30,001 - $40,000
$40,001 or more
4. Sources of Income (check all that apply):
*
Employment
Social Security
Disability
Retirement/Pension
SNAP/ Food Assistance
Other
Section 3: Membership Request
1. Which Membership Level are you applying for?
*
Social Fit – Includes Social Club Only Access
Active Fit – Includes Gym Only Access
2. Have you previously been a member of Active Generations?
*
Yes
No
3. When was your most recent membership?
Section 4: Financial Need
1. Briefly describe why you are applying for a reduced membership rate:
*
2. How would a scholarship help you participate in Active Generations programs and services?
*
Section 5: Required Documentation
1. Please select which of the following documents you will provide copies of in order to verify income eligibility (documents can be uploaded below or submitted in-person at any Active Generations facility):
*
Most recent tax return OR proof of income (e.g., pay stub, benefits statement)
Any other documentation that supports your application (e.g., SNAP approval letter)
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Section 6: Certification
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that submission of false information may result in denial or revocation of a scholarship. Signature:
*
Today's Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: