Financial Assistance Application

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

Membership/Program Information

Please indicate Membership/Program you are applying for:

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.

Drop files here or
Accepted file types: pdf, doc, docx, jpg, Max. file size: 512 MB.

    Applicant Contact Information

    Applicant Name(Required)
    Address(Required)
    MM slash DD slash YYYY
    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
     

    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

    Is any portion of your membership or program fees reimbursable by your insurance company?
    MM slash DD slash YYYY