FINANCIAL ASSISTANCE REQUEST FORM

Transcription

1 Applicant Name: Member ID # FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY Staff member receiving / reviewing applicatin (print name) FINANCIAL ASSISTANCE REQUEST FORM YMCA f Greenville Open Drs Prgram IMPORTANT: Please read the fllwing infrmatin carefully befre cmpleting the applicatin prcess. The YMCA f Greenville requires that individuals prvide the requested infrmatin n the attached frm regarding incme and family size s that it can prvide financial assistance in a fair and cnsistent manner. The YMCA als requires that individuals reapply when requested t keep the infrmatin n their applicatin updated. Yur fees are subject t increase when yu reapply. If yu d nt reapply when requested, yur enrllment may be terminated. In rder t eligible fr financial assistance, the applicant must: 1. Live r wrk in YMCA branch service area. 2. Be apprved based n their financial need. 3. Be reviewed annually fr eligibility. Please use the check list prvided belw t ensure all dcumentatin listed belw is prvided in rder t prcess yur request fr Financial Assistance: 1. Cmpleted Financial Assistance Applicatin (REQUIRED). Please ensure applicatin is cmpleted, legible and signed. 2. Cpy f mst recent tax return. NOTE: If yu d nt have a cpy f yur recent tax return, yu may btain ne by calling the IRS at If yu did nt file taxes this year, r if yu d nt have the ther dcuments required belw, please submit a letter explaining yur persnal situatin. 3. Cpy f tw recent pay stubs fr each wrking persn within the husehld. Reasn nt submitted: 4. Cpy f ne mnths bank statement. Reasn nt submitted: 5. Cpy f scial security r disability checks. Nt applicable because: 6. Cpy f recent welfare benefits, fd stamps, and/r sectin 8 husing letter. Nt applicable because: 7. Cpy f unemplyment benefits statement. Nt applicable because: 8. Prf f child supprt. Nt applicable because: 9. Prf f alimny. Nt applicable because: 10. If yu have n incme, a ntarized letter frm persn(s) wh prvide yur mnthly living expense is required. If yu d nt prvide the required dcumentatin, yur applicatin prcess will be delayed until all dcumentatin is received and applicatin is filled ut cmpletely. N prgram spaces will be placed n hld while the applicatin is in an incmplete status. Please allw 7-10 business days t prcess yur applicatin. After this perid, yu may call Amy LeRy ( ) t see if yur applicatin has been apprved r t see if additinal infrmatin is needed. Please als allw at least 2 weeks t prcess yur schlarship befre a prgram registratin deadline in rder t guarantee a spt int the prgram. If yu have prvided a valid address, yu will receive ntificatin via nce the applicatin has been prcessed stating whether r nt yu have been apprved. If n address is prvided, yu will be sent a letter via regular mail.

2 YMCA f Greenville Schlarship Applicatin Tday s Date: / / Applicant Name: DOB: / / Gender: Male Female Current Address: City, State, Zip: Phne (H): (C): Have yu previusly applied fr a YMCA Schlarship? ( ) Yes ( ) N If s, date f applicatin? Are yu currently a YMCA member? ( ) Yes ( ) N If yes, at which branch? Are yu currently receiving financial assistance frm any ther YMCA branch within ur Assciatin? ( ) Yes ( ) N If yes, fr which branch/prgram: Yur Emplyer s Name (if unemplyed, please specify): Yur Emplyer s Address: Are yu emplyed full time r part time? If yu are a STUDENT, are yu currently enrlled in schl? ( ) Yes ( ) N Name f Schl: Marital Status (please check ne): ( ) Single ( ) Married ( ) Separate/Divrced ( ) Widwed Spuse s Name: Date f Birth: / / Spuse s Emplyer s Name (if unemplyed, please specify): Spuse s Emplyer s Address: Is yur spuse emplyed full time r part time? Please list the first name, last name, gender and date f birth f all dependents living in yur husehld. Yu may be required t shw prf f residency. Please check all prgrams belw fr which yu wuld need assistance. ( ) Membership ( ) Aquatics ( ) Yuth Sprts ( ) Summer Day Camp ( ) After Schl* ( ) Classes ( ) Other (Please List): * If applying fr After Schl, please list: Child 1 Name: Schl: Child 2 Name: Schl: Child 3 Name: Schl: Child 4 Name: Schl: In an effrt t assist yu in ther areas that may be f benefit t yu ver the next year, please explain what yur gals are (i.e. get ut f debt, get training, etc.): In what ther areas wuld yu be interested r like assistance (check all that interest yu): ( ) Financial Planning ( ) Budgeting ( ) Health Educatin ( ) Literacy Prgrams ( ) Family Camp ( ) Cllege Prep ( ) Teen Achievers ( ) Other (Please List):

3 Incme/Expense Wrksheet Incme (list all mnthly incme where applicable) Grss mnthly incme $ Spuse's grss mnthly incme $ Other mnthly incme fr all adults ver the age f 18 $ Child Supprt (if receiving) $ Scial Security / Disability (if receiving) $ Welfare (if receiving) $ Aid t Dependent Children (if receiving) $ Fd Stamps (if receiving) $ Unemplyment Benefits (if receiving) $ Alimny (if receiving) $ Pensin / Retirement (if receiving) $ Husing Assistance (if receiving) $ Other incme (please explain) $ Expenses (list all mnthly expenses) Rent / Mrtgage $ Vehicle Payments $ Utilities $ Phne Service $ Child Care $ Fd $ Credit Cards $ Medical $ Child Supprt $ Insurance $ Other expenses (please explain) $ TOTAL MONTHLY EXPENSES $ TOTAL MONTHLY INCOME $ Hw much d yu think yu can pay per mnth fr yur membership? Release Frm 1. I certify the abve infrmatin t be true. I understand that if any infrmatin is fund t be false, my membership may be subject t terminatin. 2. The YMCA believes a strng sense f wnership and pride is develped if the financial assistance recipient has cntributed t the cst f their YMCA participatin. I understand I will be asked t pay a prtin f the fees thrugh a mnetary cmmitment and that failure t cmplete my financial cmmitment will prhibit me frm applying again until thse fees are paid. 3. If my financial circumstances imprve r reach a level where I n lnger require assistance, I agree t ntify the YMCA s that thers in need may avail themselves f assistance. Applicant Signature Date Spuse Signature Date

4 Types f Memberships ADULT: a membership fr ne persn wh is between 24 and 64 years f age. FAMILY/HOUSEHOLD: a membership fr tw adults and any children under the age f 18 r any dependents wh can prve they live in the husehld.* YOUNG ADULT: a membership fr ne persn wh is between the ages f 13 and 23. SINGLE PARENT FAMILY: a membership fr a single parent and any children under the age f 18. SENIOR ADULT: a membership fr ne persn wh is 65 years f age r lder. SENIOR FAMILY: a membership fr a husband and wife, 65 years f age r lder. * Each wrking adult needs t prvide their prf f incme. Fr each additinal adult n the membership, a $10 fee will be added t the grss mnthly rate. Applicant: S that we may better evaluate yur needs, please share yur reasns fr requesting a schlarship this year and hw yu feel yu and/r yur family wuld benefit frm a YMCA membership. Please list any extenuating circumstances that might assist us in the review prcess:

5 YMCA f Greenville Lcatins Caine Halter Family YMCA 721 Cleveland Street, Greenville, SC 29601, Eastside Family YMCA 1250 Taylrs Rad, Taylrs, SC 29698, Gerge I. Theisen Family YMCA 100 Inspiratinal Way, Travelers Rest, SC 29690, GHS Family YMCA 550 Brkwd Pint Place, Simpsnville, SC 29681, YMCA Prgram Center - GHS 100 Adams Mill Rad, Simpsnville, SC 29681, Verdae YMCA 3 Legacy Park Rad, Suite B, Greenville, SC 29607, YMCA Camp Greenville P.O. Bx 390, Cedar Muntain, NC 28718, YMCA Judsn Cmmunity Center 2 Eighth Street, Greenville, SC 29611, YMCA Teen Services 100 Adams Mill Rad, Simpsnville, SC 29681,