Financial Assistance Application

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Approved Membership Type

Scholarship

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

Applicant Contact Information

Applicant Name
Address
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Marital Status

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
 

Membership/Program Information

Please indicate Membership/Program you are appplying for:

Monthly Household Income All Sources

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

Monthly Income

Monthly Expenses

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

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.

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.

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

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