Financial Aid | YMCA of Auburn-Lewiston

Financial Aid Application

YMCA of Auburn-Lewiston
This Financial Aid Application is also available in it's original format. Please use this link if you prefer to print and complete using pen and paper.
- First Name
- Last Name
- Date of Birth
  
  MonthDayYear
- M/F
- Street Number and Address
- City
- State
- Zip Code
- Primary Phone Number
- Primary Phone Type
- Secondary Phone Number
- Secondary Phone Type
- Email
  example@example.com
- Note: Only two adults are allowed on a family membership.
- Household Member 2
- H2 First Name
  Household Member 2 First Name
- H2 Last Name
  Household Member 2 Last Name
- H2 DOB
  Household Member 2 Date of Birth
- H2 M/F
  Household Member 2 Male/Female
- H2 Relationship
  Household Member 2 Relationship
- H2 Membership
  Include Household Member 2 in Y membership?
- Household Member 3
- H3 First Name
  Household Member 3 First Name
- H3 Last Name
  Household Member 3 Last Name
- H3 DOB
  Household Member 3 Date of Birth
- H3 M/F
  Household Member 3 Male/Female
- H3 Relationship
  Household Member 3 Relationship
- H3 Membership
  Include Household Member 3 in Y membership?
- Household Member 4
- H4 First Name
  Household Member 4 First Name
- H4 Last Name
  Household Member 4 Last Name
- H4 DOB
  Household Member 4 Date of Birth
- H4 M/F
  Household Member 4 Male/Female
- H4 Relationship
  Household Member 4 Relationship
- H4 Membership
  Include Household Member 4 in Y membership?
- Household Member 5
- H5 First Name
  Household Member 5 First Name
- H5 Last Name
  Household Member 5 Last Name
- H5 DOB
  Household Member 5 Date of Birth
- H5 M/F
  Household Member 5 Male/Female
- H5 Relationship
  Household Member 5 Relationship
- H5 Membership
  Include Household Member 5 in Y membership?
- Household Member 6
- H6 First Name
  Household Member 6 First Name
- H6 Last Name
  Household Member 6 Last Name
- H6 DOB
  Household Member 6 Date of Birth
- H6 M/F
  Household Member 6 Male/Female
- H6 Relationship
  Household Member 6 Relationship
- H6 Membership
  Include Household Member 6 in Y membership?
- Please fill in values for both the Applicant and 2nd Adult where applicable.
- Work Hours (Applicant)
  Hours worked per week on average
- Work Hours (2nd Adult)
  Hours worked per week on average
- Hourly Wage (Applicant)
  Income in dollars ($) per hour
- Hourly Wage (2nd Adult)
  Income in dollars ($) per hour
- Assistance from Social Security or SSDI (Applicant)
  NOT YOUR SS NUMBER! Income from assistance in dollars ($) per month
- Assistance from Social Security or SSDI (2nd Adult)
  NOT YOUR SS NUMBER! Income from assistance in dollars ($) per month
- Unemployment Assistance (Applicant)
  Income in dollars ($) per month
- Unemployment Assistance (2nd Adult)
  Income in dollars ($) per month
- TANF Assistance (Applicant)
  Income in dollars ($) per month
- TANF Assistance (2nd Adult)
  Income in dollars ($) per month
- Child Support or Alimony Assistance (Applicant)
  Income in dollars ($) per month
- Child Support or Alimony Assistance (2nd Adult)
  Income in dollars ($) per month
- Food Stamps Assistance (Applicant)
  Income in dollars ($) per month
- Food Stamps Assistance (2nd Adult)
  Income in dollars ($) per month
- Housing Assistance (Applicant)
  Income in dollars ($) per month
- Housing Assistance (2nd Adult)
  Income in dollars ($) per month
- Pension or Retirement (Applicant)
  Income in dollars ($) per month
- Pension or Retirement (2nd Adult)
  Income in dollars ($) per month
- Worker’s Comp or Disability Assistance (Applicant)
  Income in dollars ($) per month
- Worker’s Comp or Disability Assistance (2nd Adult)
  Income in dollars ($) per month
- Assistance from Family (Applicant)
  Income in dollars ($) per month
- Assistance from Family (2nd Adult)
  Income in dollars ($) per month
- Other Funding/Income (Applicant)
  Income in dollars ($) per month
- Other Funding/Income (2nd Adult)
  Income in dollars ($) per month
- Gross Annual Income (Applicant)
  Total before taxes in dollars ($) per year
- Gross Annual Income (2nd Adult)
  Total before taxes in dollars ($) per year
- Supporting Documents
  As proof of financial standing, applicants must provide the following documents for all adults living in the household:
  - Most recent tax W2
  - Check stubs for past two pay periods
  - Verification of aid from federal, state or local agencies (WIC, SSDI, SSI, TANF, HUD, SNAP, etc.)
  - Unemployment benefit statement
  - Letter of residency if living in a group home or shelter
  - Child support/alimony agreement
  - Denial Letter from DHHS (for childcare application only)
- Upload Supporting Documents (file size limit 2MB)
  
  Please upload all applicable documents. Submissions without proper documentation will not be considered. Documents above the 2MB limit may be emailed to info@alymca.org.
  Cancelof
- Are there extenuating circumstances that should be considered while reviewing your application? Please explain.
- If you have no income, how are you meeting your expenses? Please explain.
- Y Membership Type
- Programs of Interest
  
  Specific Program:
- Monthly Contribution
  How much do you feel you can you contribute to the cost of membership each month?
- Programs Contribution
  How much do you feel you can you contribute to the cost of programs each month?
- Caregiver Accompaniment
  
  If this application is for a client that needs to be accompanied by a caregiver, please complete the following section:
- Caregiver Organization
- Caregiver Contact Name
- Caregiver Phone Number
- Caregiver Email
- Applicant's Statement
  
  I certify that all information provided is true and accurate. I will notify the YMCA of Auburn-Lewiston Welcome Center of any changes to my family or financial status immediately should they occur.
- Applicant's Signature
- Date
  
  MonthDayYear
  Date
- Verify you are human
- Note: The Y conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs the Y reserves the right to cancel membership, end program participation, and remove visitation access.
- Should be Empty:

Financial Aid Application