Membership Financial Assistance Enter your information to see if you qualify! Primary Member First Name Primary Member Last Name Primary Phone Primary Email Birthdate Residence Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Are you new to Y-Access or is this a renewal? New Renewal Best Day/Time to Call Membership (Please Check One) Teen/Youth One individual, age 8-17 Young Adult One individual, age 18-26 Adult One individual, age 27-64 Senior Adult One individual, age 65+ One Adult Household One individual, age 18+, any dependents 21 and under Two Adult Household Two individuals, age 18+, no dependents Household Two individuals, age 18+, any dependents 21 and under Senior Household Two individuals, both 65+, no dependents Programs (if applicable) Sports Aquatics Community Health Program Adult Program Total Household Members Number of adults/kids living in residence Unemployment Social Security/Disability Wages and Tips Food Stamps/WIC Child/Spousal Support Worker's Compensation Rental/Utility Assistance Other Loans, Grants, Gifts, etc. Income Source 1 One file only.128 MB limit.Allowed types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip. Income Source 2 One file only.128 MB limit.Allowed types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip. Income Source 3 One file only.128 MB limit.Allowed types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip. Do you receive "in-kind support" such as a family member or friend paying for expenses? If so, please explain. How much can you afford to pay for your membership/program? Tell us more about your situation and how the Y can help. Honesty Agreement I certify that the information included in this application is true and complete to the best of my knowledge, and that I do not have additional income not represented on this form. I agree to provide additional information to support this information, if requested. I understand my Y-Access assistance is based on need. In the event that my situation changes, I will contact the YMCA immediately. I understand that if I falsify this information, I will not be eligible for assistance now and/or in the future. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
