The YMCA strives to make our programs and membership available to all who will benefit from them, regardless of their ability to pay. All financial assistance is granted on a sliding scale based on income and need. All information is kept confidential.
Please fill out the form below to see if a membership scholarship may apply to you. Verification of income will be required to confirm need. See below for the required documents that must be provided to the Y within one (1) month of this application submission.
Note: Scholarship percentages calculated on the website may differ from what you are actually eligible. This is used to get the process started and give an idea of what you may be eligible for.
Primary Applicant Information
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Name | |
Date of Birth | |
Address | |
City | |
State | |
Zip | |
Email | |
Cell Phone Number | |
Employeer | |
Occupation | |
Second Adult Applicant Information |
Name | |
Date of Birth | |
Address | |
City | |
State | |
Zip | |
Email | |
Cell Phone Number | |
Employeer | |
Occupation | |
Assistance Request |
What kind of membership are you interested in? |
What programs are you interested in? |
Household Information |
How many people are in your household?
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Monthly Income Information
Please fill in your monthly income as accurately as possible into the calculator below. If you already know your total monthly income, just put that number in the "other" input box to see your calculation. |
Use numbers only. No dollar signs ($), periods (.), commas (,) or letters. Thank you. |
Number of Family Members
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Monthly Wages, Salaries, Tips for you (before taxes) | |
Monthly Wages, Salaries, Tips for your Second Adult (before taxes) | |
Monthly Unemployment compensation you receive | |
Monthly Social Security compensation you receive | |
Monthly Child Support you receive | |
Other monthly income you receive (e.g. Food Stamps, Aid to Dependent Child, 401K, Alimony, etc). | |
Additional Information |
Please inform us of any special circumstance that affects your income Examples; recent unemployment, medical bills etc. | |
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In order to calculate your potential discount correctly, please ensure you used numbers only. No dollar signs ($), periods (.), commas (,) or letters. Thank you. |
Monthly Income | |
Annual Income | |
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*After submitting this form, the following documents must be delivered to the Y within one (1) month in order for your application to be considered:
Income Information for All Adults in the Household:
- Most Recent Income Tax Returns (Form 1040 pages 1 and 2 ONLY; or 1040EZ)
- Most Recent 4 Paystubs
- Unemployment
- SSI
- SNAP
Housing Information:
- Lease or mortgage statement show monthly payment
- TANF / Section 8 Assistance (if applicable)
Unfortunately, budgetary demands limit the number of families that we can assist. If you are unable to submit the required documents within one (1) month to complete your application process, we will understand that you do not wish to participate in this program at this time. To protect your confidential information, your application will be safely discarded. Should you wish to reapply, our policy requires a waiting period of six months and that you resubmit all current financial data when re-applying.
Once complete information is provided to the Y, the application will be reviewed and you’ll receive a determination in 2-4 weeks. |