The YMCA is a trusted organization that helps millions of people every year. However, sometimes they need to keep information confidential. That's why they have a confidential form that anyone can use to submit information anonymously. This form is for anyone who wants to report something that happened at the YMCA or wants to share some feedback. If you have any concerns or issues at the YMCA, this is the best way to address them. You can fill out the form online or print it out and bring it in person. The YMCA takes these reports seriously and will do everything they can to resolve the issue. Thank you for helping us keep our community safe!
| Question | Answer |
|---|---|
| Form Name | Ymca Confidential Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ymca application for financial assistance, ymca overnight, confidential application assistance, ymca confidential |
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 |
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Do you receive income? |
q Yes |
q No |
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Phone |
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Are you employed? q Yes |
q No |
q Retired |
q P/T q F/T |
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Address |
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Are you enrolled in school? |
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Do you own or rent a home? |
q Own q Rent |
q Unhoused |
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Apt. |
City |
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Zip |
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SECONDARY ADULT |
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Do you receive income? |
q Yes |
q No |
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First & Last Name |
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Are you employed? q Yes |
q No |
q Retired |
q P/T q F/T |
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Are you enrolled in school? |
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q Own q Rent |
q Unhoused |
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Do you own or rent a home? |
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FAMILY MEMBERS |
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First & Last Name |
Date of Birth |
Grade |
Name of school(s) currently attending |
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First & Last Name |
Date of Birth |
Grade |
Name of school(s) currently attending |
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First & Last Name |
Date of Birth |
Grade |
Name of school(s) currently attending |
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First & Last Name |
Date of Birth |
Grade |
Name of school(s) currently attending |
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First & Last Name |
Date of Birth |
Grade |
Name of school(s) currently attending |
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WHAT PROGRAM(S) ARE YOU APPLYING FOR? Check all that apply.
q MEMBERSHIP |
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q PROGRAMS |
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INDIVIDUAL |
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qChild Care |
qDay Camp |
qSwim Lessons |
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q Adult |
q Senior |
q Youth |
q Summer |
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q Holiday Camp |
q Group Lessons |
FAMILY |
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q School year q Summer Camp |
q Other |
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q One adult w/kids |
q Two adults |
qResident Camp |
qYouth Sports |
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q Two adult w/kids |
q Three adults |
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q Other
Revised December 27, 2018
HOUSEHOLD MONTHLY INCOME
Include all sources of income in totals: |
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1. |
Your total monthly gross income |
$ |
2. |
Secondary adult total |
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monthly gross income |
$ |
3. |
Other adults in household |
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total monthly gross income |
$ |
Total Household |
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Monthly Gross Income: |
$ |
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Total Annual Gross Income |
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(monthly x12) |
$ |
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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 |
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statements |
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q Unemployment |
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benefit statement |
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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: |
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q Paid employment |
q Unemployment benefits |
Does your child qualify for free or reduced lunch? |
q Yes |
q No |
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q Child Support |
q Alimony |
q Disability |
Do you receive any type of public benefit? |
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q Social Security (SSI) |
q Pension/Retirement |
(Cal Fresh, Housing, 3rd Party Payer, etc.) |
q Yes |
q No |
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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? $ |
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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
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: |
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q Date income verified |
Program Category: |
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% Approved: |
$ Approved: |
$ Member Pays: |
Staff Name: |
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Signature: |
Supervisor Name or Second Approver: |
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Signature: |