YMCA OF WESTERN NORTH CAROLINA

Financial Assistance Application/Screening Form

Deadline Date: July 3, 2012 ~ DATE OF APPLICATION: ______________________________________
While the deadline is July 3rd, we will continue to review these as long as there is funding available. In the event that our
funding is exhausted, we will waitlist eligible applicants in the event that additional funding becomes available.

Afterschool 2012 - 2013

Parent Name(s)________________________________________________Home # _____________________ Cell # _____________________ Work # ______________________
Childs Name: __________________________________________________Age: _____ Sex: _____ Race: __________ Grade:_____
Childs Name: __________________________________________________Age: _____ Sex: _____ Race: __________ Grade:_____
Childs Name: __________________________________________________Age: _____ Sex: _____ Race: __________ Grade:_____
The school location of the afterschool program? __________________________________________
Is your child currently in the YMCA Afterschool Program? ______ Site: ________________________
Made available through generous contributions to our Healthier Communities Campaign, the YMCA is able to provide financial
assistance. As a recipient of a YMCA scholarship, I would be willing to volunteer during the Annual Fund Raising Campaign (Healthier
Communities Campaign)? _______________

IT IS A REQUIREMENT THAT YOU APPLY FOR SUBSIDY FIRST THROUGH BUNCOMBE COUNTY CHILD CARE SERVICES.

Have you applied for county Child Care Subsidy Vouchers?________

In order to qualify for financial assistance for child care, parents must meet the
programs guidelines. Parents must be working full-time (30 or more hours per
week) or enrolled in school full-time.

How many hours per week do you work? _______ Your spouse?_______

Are you a single parent? _______

Are you a full time student? ________ Attach your full-time school schedule.

Have you attached copies of your last three paycheck stubs? _________

Have you attached a copy of the 1st page of your 2011 tax return? _______

Amount you could possibly pay per week? _________________

There is a registration fee of $50.00 (1 child)/$75.00 (2+ children).

This amount is not covered by financial assistance.

I authorize the YMCA to share my story.

FINANCIAL INFORMATION
My total Family Income is:
Monthly

$______________

Annually

$______________

Do you receive any of the following?

If so, how much PER MONTH?
AFCD

$______________

Food Stamps

$______________

Child Support

$______________

Social Security

$______________

Pensions

$______________

Other

$______________

Yes

No

Please list any extenuating circumstances for us to consider when reviewing your
application:
__________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _____________________________________
_____________________________________________________________________________________________________________________________ _____________________________________
__________________________________________________________________________________________________________________________________________________________________
If your child has previously received Financial Assistance, how do you feel the program has helped your child?
__________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _____________________________________
I hereby acknowledge that all of the information provided on this application is complete, true, and correct, and that if I am offered
and accept Financial Assistance, I understand that my portion of the child care program cost must be paid on time and my account
must be kept current. Failure to comply with the payment polices may jeopardize future financial assistance. Initial ________________
Parent Name:
________________________________________________________________________
Date:
____________________________________________
OFFICE USE ONLY:
Previous FA:
________________________________________________________________
________________________________________________________________
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