The YMCA of the Greater Tri-Valley

The YMCA of the Greater Tri-Valley

Confidential Scholarship Request

Please fill out this form, attached the necessary documents (photocopies only), and return to:

YMCA of the Greater Tri-Valley

25 Oxford Road

New Hartford, New York13413

Branch – New Hartford Family YMCA

If approved for assistance, the fee balance must be paid via check, cash, or credit card, or arrangements must be made through our automatic payment plan. Only the Regional Director, Membership Services, can grant an exception. Please print all information.

Date of Application / Social Security Number
Name / Home Phone Number
Address / Work Phone Number
City / Cell Phone Number
State, Zip Code / Place of Employment
Length of Employment
Spouse/Child(ren)’s Name / Age / School/Employer / Birth Date
1
2
3
4
5
6

Are you a single-parent household?[ ] Yes[ ] No

Are you a caregiver for immediate family member? [ ] mother [ ] father [ ] child w/disabilities

Scholarship Application is for:

[ ] Membership for ______

[ ]Program Participation ______

[ ]Child Care (you must have been denied entitlements benefits from the Department of Human Services. Please attach your denial letter with this application.)

Have you applied for scholarship assistance before at the YMCA [ ] If Yes, when ______[ ] No

Your present income level is:

• Under $5,000
• Under $8,000
• $8,001 to $12,000
• $12,001 to $15,000
• $15,001 to $18,000
• $20,001 to $25,000
• Over $25,000

Would you be willing to volunteer service at the YMCA?

[ ] Yes doing ______

______

[ ] No

What is the dollar amount that you are willing or able to pay each month?

Membership$______per month

Program$______per session

Child Care$ ______per week

What benefits do you see in having this scholarship to join the YMCA as a member or participant? Why are you applying for scholarship assistance?

______

______

Please itemize your monthly income and expenses

INCOME / EXPENSES
Wage, salaries, tips / Rent/mortgage
Unemployment compensation / Utilities
Social Security compensation / Food
Child Support / Clothing
Aid to dependent children / Phone
Food stamps / Car/Insurance
401 K/Retirement Funds / Alimony
Alimony / Child Support
Other / Medical
TOTAL INCOME / TOTAL EXPENSE

Please verify your household income by attaching a copy of all that apply to you:

1040 or 1040A Internal Revenue ServiceTax Statement (last year’s)

SSI allocation statement

DSS Statement

Social Security Benefits Statement

Child Support Statement

2 Most Recent Paystubs

anyone in household with an income

I understand that the assistance requested is dependent upon verification of my family’s income, residency, and dependents listed. If I wish to continue to receive services from the YMCA, I must reapply at the end of the scholarship period. The scholarship program is a month-to-month membership that can be revoked at any time that I (the applicant) fail to pay by the due date. I am requesting assistance from the YMCA of the Greater Tri-Valley due to personal circumstances and I certify that all information provided is correct.

Applicant’s signature: ______Date: ______

Received by: ______Date ______

Please allow a minimum of two weeks for this application to be processed and approved (or denied) by the YMCA. You will be contacted in writing by the YMCA as to the status of this application. Thank you.

Application Reviewed on ______

Denied – Reason: ______Notified Applicant: ______

Approved: Amount $ ______Notified Applicant ______

Scholarship Period:______