OPEN DOORS. The mission of the YMCA is to provide programs that build healthy spirit, mind and body for ALL. To

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1 OPEN DOORS The mission of the YMCA is to provide programs that build healthy spirit, mind and body for ALL. To ensure that these programs remain available for ALL, regardless of a person s financial situation, the YMCA of Greater San Antonio has created the Open Doors scholarship program. Open Doors is designed to provide families, children and adults with the financial assistance they need to obtain quality Child Care, Youth and/or Health & Wellness services. Funding for Open Doors is made possible through the generous support of the Y Partners Annual Campaign in addition to grants from the United Way, City of San Antonio and other foundations. Scholarships are awarded on a first-come, first-served basis and are subject to available resources. Therefore scholarships may be offered for a limited duration of time, and/or you may be asked to pay a portion of program fees.

2 All information requested must be provided in full before applications can be processed. Please allow up to three weeks for your application to be processed once it is received/complete. Documentation required at time of application includes: Household income: For all working adults within the household, please provide one of the following: a) One month of current pay stubs b) Tax Return (Current year required after April 15) Residency: For the person(s) who will receive financial assistance, please provide one of the following: a) Valid Texas Drivers License/State ID b) Current utility bill, such as electric, water or garbage/trash collection c) Current lease agreement If applicable, please provide the following as well: Proof of government funds, such as housing, Social Security, disability, etc. Proof of child support payments Proof of all other income such as contratual work, unemployment checks, etc. School schedule and ID if college student Copy of all Tax Return schedules if self-employed Monthly Income Chart $ Household s Monthly Gross Income (before deductions) $ Monthly Child Support $ Monthly Social Security/Disability $ Monthly Government Assistance (housing, TANF) $ Other Monthly Income (eg: workers comp, unemployment, investments, add tl household member) $ Total Monthly Household Income Monthly Expense Chart $ Monthly mortgage/rent $ Monthly auto expenses $ Monthly utilities (all) $ Monthly food $ Monthly medical $ Other Monthly Expenses $ Total Monthly Household Expenses

3 Branch: Date: Name: Member#: ADULT 1/PARENT 1 ADULT 2/PARENT 2 Open Doors Scholarship Application Participant s Name: Date of Birth: Scholarship requested for: (choose only one) Membership Aquatics Active Older Adults Parent Child Programs After School Care Preschool Day Camp Resident Camp Youth Sports Teen Programs Other: Name: Date of Birth: Home Phone: Work Phone: Alternate Phone: Address: City: Zip Code: Council District: Place of Employment: Hours Worked Weekly: Monthly Gross Income: Paid: Weekly Bi-weekly 1 st & 15 th Monthly Student, How many hours? Name: Date of Birth: Home Phone: Work Phone: Alternate Phone: Address: City: Zip Code: Council District: Place of Employment: Hours Worked Weekly: Monthly Gross Income: $ Paid: Weekly Bi-weekly 1 st & 15 th Monthly Student, How many hours? Ethnicity: Is the applicant for whom this application is being completed Hispanic? Yes No If Yes, please select the appropriate Ethnicity and Race from those below: Hispanic/White Hispanic/Black Hispanic/Asian Mixed/Multi-Race Hispanic/American Indian Hispanic/Pacific Islander Hispanic/Other: If No, please select the appropriate Ethnicity and Race from those below: Caucasian/White African American/Black Asian Mixed/Multi-Race American Indian/Alaska Native Hawian/Pacific Islander Other Including yourself, what is the total number of household members? Adults Children (Please count all your household members who regularly live with you, including those who are temporarily away from home.) List all Household Members Including Applicant/Parent, Siblings and/or Spouse First Name Last Name Gender Age Relationship to Applicant I certify that the above information is true and complete to the best of my knowledge. I agree to inform the YMCA of Greater San Antonio immediately of any changes in income or family size. I understand that false or incomplete information could jeopardize my financial assistance and that I must apply again every year. Applicant s Signature Witness Signature Date Print Witness Name Please use the Notes field on the reverse side for further explanations, if needed.

4 OFFICE USE ONLY Program approval record * If scholarship discount is different from standard discount amounts, please complete and attach a Discount Documentation Form for further explanation. Staff s Signature Date Notes:

5 Adjustments, Discounts, and Scholarships Documentation Form Date: Branch: Member Number: Select One: Member Name: Community Discount Branch Discount Adjustment/Correction Financial Assistance Amount: Y-Metro Code: Explanation: Input By: Approved By: *Note: Director on Duty must approve all exceptions to policy.