Ymca Confidential Form PDF Details

At the heart of the YMCA of Silicon Valley's mission is a profound commitment to inclusivity, ensuring that everyone, regardless of their financial situation, has access to its programs and services. This commitment is embodied in the YMCA Confidential Application for Financial Assistance. The form serves as a bridge for individuals and families who wish to participate in YMCA activities but face financial barriers, enabling them to apply for reduced membership rates or program fees. Applicants are asked to provide detailed information, including income sources, employment status, household composition, and any relevant circumstances that could influence their need for financial assistance. Critical to this process is the requirement for income verification, where applicants must furnish documents such as pay stubs, social security checks, or tax returns, within a specific timeframe to validate their claims. Moreover, the form thoughtfully inquires if there are other factors to consider, emphasizing a personalized approach to financial aid. By acknowledging the completed application, applicants affirm the accuracy of their information and agree to comply with YMCA policies, highlighting a mutual commitment to integrity and community support.

QuestionAnswer
Form NameYmca Confidential Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesymca application for financial assistance, ymca overnight, confidential application assistance, ymca confidential

Form Preview Example

YMCA OF SILICON VALLEY

Confidential Application

YMCA Financial Assistance

EVERYONE IS WELCOME

The YMCA welcomes all who wish to participate and believes that no one should be denied access to the Y based on their ability to pay. Through our Annual Campaign, the Y provides assistance to youth, adults and families based on individual needs and circumstances.

PRIMARY ADULT - PLEASE PRINT LEGIBLY

First & Last Name

 

 

Do you receive income?

q Yes

q No

 

(

)

 

 

 

 

 

 

Phone

E-mail

 

Are you employed? q Yes

q No

q Retired

q P/T q F/T

Address

 

 

Are you enrolled in school?

q Part-Time

q Full-Time

 

 

 

 

 

 

 

 

 

 

Do you own or rent a home?

q Own q Rent

q Unhoused

Apt.

City

 

Zip

 

 

 

 

SECONDARY ADULT

 

 

 

 

 

 

 

 

 

 

Do you receive income?

q Yes

q No

 

First & Last Name

 

 

Are you employed? q Yes

q No

q Retired

q P/T q F/T

 

 

 

 

E-mail

 

 

Are you enrolled in school?

q Part-Time

q Full-Time

 

 

 

q Own q Rent

q Unhoused

 

 

 

 

Do you own or rent a home?

FAMILY MEMBERS

 

 

 

 

 

 

First & Last Name

Date of Birth

Grade

Name of school(s) currently attending

 

 

 

First & Last Name

Date of Birth

Grade

Name of school(s) currently attending

 

 

 

First & Last Name

Date of Birth

Grade

Name of school(s) currently attending

 

 

 

First & Last Name

Date of Birth

Grade

Name of school(s) currently attending

 

 

 

First & Last Name

Date of Birth

Grade

Name of school(s) currently attending

 

 

 

WHAT PROGRAM(S) ARE YOU APPLYING FOR? Check all that apply.

q MEMBERSHIP

 

 

q PROGRAMS

 

 

 

INDIVIDUAL

 

 

qChild Care

qDay Camp

qSwim Lessons

q Adult

q Senior

q Youth

q Summer

 

q Holiday Camp

q Group Lessons

FAMILY

 

 

q School year q Summer Camp

q Other

 

 

 

 

 

 

q One adult w/kids

q Two adults

qResident Camp

qYouth Sports

 

 

 

q Two adult w/kids

q Three adults

 

 

 

 

q Other

Revised December 27, 2018

HOUSEHOLD MONTHLY INCOME

Include all sources of income in totals:

 

1.

Your total monthly gross income

$

2.

Secondary adult total

 

 

monthly gross income

$

3.

Other adults in household

 

 

total monthly gross income

$

Total Household

 

Monthly Gross Income:

$

Total Annual Gross Income

 

(monthly x12)

$

INCOME VERIFICATION

Please bring one of the following document(s) at the time of your application or within 14 days of approval. If verification is not completed your assistance will be terminated. Note: The Y will not retain these documents so

you do not need to provide us copies.

q TANIF

q Disability benefit statement

q Last 2 months paystubs

q Social Security check copy

q IRS Form 1040 or 1040EZ

q Pension/Retirement

q Self-employed IRS Schedule C

statements

 

q Unemployment

 

benefit statement

 

Are there any other factors that we should take into consideration in evaluating your need for assistance?

Sources of income (check all that apply):

Sources of county/government support:

 

 

q Paid employment

q Unemployment benefits

Does your child qualify for free or reduced lunch?

q Yes

q No

q Child Support

q Alimony

q Disability

Do you receive any type of public benefit?

 

 

q Social Security (SSI)

q Pension/Retirement

(Cal Fresh, Housing, 3rd Party Payer, etc.)

q Yes

q No

 

 

 

 

 

 

Do you currently have any foster children?

q Yes

q No

The full rate of your membership category is $

How much can you afford to pay? $

 

 

ACKNOWLEDGEMENT

I acknowledge by my signature below, that all of the information on this form is accurate and complete. I agree to provide additional documentation to verify need, if requested. I am aware that on-time program payments are required to maintain enrollment in Y program or membership. I understand I am subject to the rules and regulations of the YMCA. I acknowledge that I will be notified when it is time to reapply for financial assistance. I acknowledge that each application is reviewed and approved independently. If

there are changes to my income, I will notify the YMCA.

Signature

Date

Your signature indicates that you understand the policies and procedures of the YMCA Membership for all programs.

FOR STAFF USE ONLY

Branch: CC CN EC EPA EV MM

NW PA SEQ

SW SV (Circle one)

Membership Category:

 

q Date income verified

Program Category:

 

 

% Approved:

$ Approved:

$ Member Pays:

Staff Name:

 

Signature:

Supervisor Name or Second Approver:

 

Signature: