Emergency Assistance Fund Application
Legal Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Branch
*
Please Select
Daily YMCA
Downtown YMCA
Herman & Kate YMCA
Okmulgee YMCA
Owasso YMCA
R.C. Dickenson YMCA
Skiatook Pool
Tandy YMCA
W.L. Hutcherson YMCA
Y at East Central
Y at TCC Metro
Y at TCC Northeast
Y at TCC Southeast
Y at TCC West
Y at Union
Zarrow YMCA
Job Title
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred method of communication
*
Phone
Email
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What type of assistance is needed?
*
Medical
Death in the Family
Critical Bills
Unexpected Bill
Other
Please describe your current financial/resource situation and explain your specific request. Attach any appropriate documentation that will support your request.
*
Describe specifically what is needed, how much, and duration (i.e. rent/mortgage, power, water, medicine, etc. along with supplemental documentation detailing amounts).
*
If requesting financial assistance, how much is needed and by what date?
Amount Requested
Date Needed
-
Month
-
Day
Year
Date
Please upload supporting documentation (Copies of Bills/Expenses Paid, Proof of Income, Wage Garnishments, Medical Bills, Proof of Medical Insurance Deductible, Proof of Disaster, Proof of Lost Wages, etc.) We will review your application and follow-up with you within 5 days.
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*
Date
*
-
Month
-
Day
Year
Date
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