Piranhas Swim Team Financial Assistance Application Parent/Guardian First Name Parent/Guardian 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 Is this your first time applying or is this a renewal? New Renewal Program Site - Select -Asheville YMCABlack Mountain YMCACorpening Memorial YMCAHendersonville Family YMCAReuter Family YMCA First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified First Name Last Name Birthdate Gender - None -FemaleMaleUnspecified Best Day/Time to Call Total Household Members Number of adults/kids living in residence Wages and Tips Unemployment (if applicable) Social Security/Disability (if applicable) Food Stamps/WIC (if applicable) Child/Spousal Support (if applicable) Worker's Compensation (if applicable) Rental/Utility Assistance (if applicable) Other (if applicable) 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 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.
