YMCA of Greater Erie

Financial Assistance Application

The YMCA of Greater Erie believes in providing membership and program services to all who desire to participate. The scholarship program, supported in part through donations to the Y’s annual campaign, provides the membership and program service to those in need within our available resources.

Membership/Program Information

Please indicate Membership/Program you are applying for:

Membership

Youth Only Membership

Swim Lesson Scholarship

Other Programs

Select Location:(Required)

Reason for Scholarship

PLEASE EXPLAIN, IN DETAIL, YOUR NEED FOR THIS SCHOLARSHIP. YOU MAY ALSO UPLOAD YOUR EXPLANATION AS A SEPERATE DOCUMENT. YOUR APPLICATION WILL NOT BE CONSIDERED WITHOUT WRITTEN EXPLANATION OF YOUR NEED.

Please explain your need for this scholarship:(Required)

Applicant Contact Information

Applicant Name(Required)

First Last

Address(Required)

Address City State ZIP

Email(Required)

Cell Phone

Cell Phone Carrier

Employer

Employer Phone Number

Gender

Date of Birth

Marital Status

Married

Single

Emergency Contact

Emergency Contact Phone Number

List All Household Members to be Included on Membership

List only children who are born to you, legally adopted/guardianed by you, and claimable on your taxes will be considered dependents. Children over the age of 18 are considered a dependent with proof of residence. You may be asked for verification.

Household Members

First Name

Last Name

DOB

Age

Relationship to Applicant

Monthly Household Income All Sources

This section must be completed or your application will be considered INCOMPLETE. You may be asked to show documentation.

Your application WILL NOT BE PROCESSED without the following: A) Most recent year’s Federal Income Tax form (1040 first two pages) B) Four recent paycheck stubs. C) Proof of child support and/or social security benefits. D) Food Stamp or cash assistance determination letter. E) Essay explaining need for scholarship

Monthly Income

Gross Wages/Salaries/Tips (4 pay stubs)

Unemployment

Social Security Compensation

Child Support

Aid to Dependent Children

Food Stamps

Alimony

Retirement/Pension

Disability

Cash Assistance

Other

Monthly Income Total

NOT REQUIRED to file Federal Tax Return? Reason:

Is any portion of your membership or program fees reimbursable by your insurance company?

Yes

If yes, under what Health Insurance plan are you currently covered?

Upload Required Documents:(Required)

Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 512 MB.

Signature of Applicant(Required)

Date(Required)