APPLICATION FOR:

MEMBERSHIP TYPE: OTHER PROGRAM:

(please check any)

REGIONAL LOCATION (please check one)

Williamsport Eastern Lycoming Jersey Shore Bradford Tioga

Child Care:
CAMP BEFORE/AFTER SCHOOL ENRICHMENT EARLY CHILDHOOD DEVELOPMENT

RIVER VALLEY REGIONAL YMCA FINANCIAL ASSISTANCE APPLICATION hjhjk

NEW APPLICATION RENEWAL APPLICATION

Date Application Submitted

STEP 1

Enter Household Information:

Date of Birth: E-Mail Address: APT: Single: Married: Separated: City: State: Zip: / _/ Age: Gender: M F

First / Last Name: Phone Number: Address: Check One:

List names (including last names if different from applicant) and ages of everyone residing in your household: First Name, Last Name 1. 2. 3. 4. 5. Age DOB
MM/DD/YY

Gender _/ _/ _/ _/ _/

Relationship
i.e. spouse, son, etc

Employment Status
i.e. working part time, student, etc

/ / / / /

MF MF MF MF MF

(Please use an additional application OR attach another document if you need extra space for additional names.)

STEP 2

Verify current total household income and submit supporting documents:

please ensure supporting documents aid in verifying total income

What is the current, combined annual household income? $

Submit a copy of your most recent federal tax return form 1040 AND a copy of ONE of the following supporting documents: Last two pay stubs, for all household members Retirement income documentation Social security or disability award letter(s) Unemployment income verification

If a current year OR prior year federal tax return - form 1040 HAS NOT BEEN FILED please submit a copy of ALL the following supporting documents that are applicable for verification of HOUSEHOLD income: Last two pay stubs, for all household members Retirement income documentation Social security or disability award letter(s) Do you receive Child Support? YES NO Unemployment income verification Temporary Cash Assistance Please provide supporting documents

If yes, what is monthly support? $_

Attach an optional letter stating the applicants specific need and/or hardship. Please include special circumstances (if any) in the letter.

STEP 3

Signature of Applicant:

Date:

The information I have provided on this form is complete and correct and I agree to provide additional documentation upon request to verify need of financial assistance. I understand that the Y provides financial assistance to the extent that resources are available and that the Y reserves the right to refuse assistance to any applicant. I also understand that my current Y account must be in good standing prior to this application being processed.

STEP 4 CHILD CARE ONLY

Camp:

Specify location below, including specific school or camp site:

Location listings are available online at RVRYMCA.org or at any Y Branch.

Before / After School Enrichment: Early Childhood Development:

All applicants are required to apply for Department of Public Welfare (DPW) Child Care Subsidy Program (CCSP) vouchers and submit a copy of your decision letter prior to our processing this application.

Submit completed application and all supporting documentation to the Y by either: MAIL: 320 Elmira Street, Williamsport PA 17701 Attn: Financial Assistance IN PERSON: At your local Y Branch