APPLICATION FOR SCHOLARSHIP MEMBERSHIP

Transcription

1 APPLICATION FOR SCHOLARSHIP MEMBERSHIP The Skagit Valley Family YMCA provides financial assistance to the extent possible to those in need. Proof of income is required and eligibility is determined by comparing your gross annual household income to the Housing & Urban Development (HUD) Income Guidelines for Skagit County. Once submitted, your application will be reviewed and you will be notified, by mail, within 14 working days; incomplete applications will not be processed and will held in pending for 14 working days. If you do not hear from us within this time period it is your responsibility to call and inquire about the status of your application. Assistance will be granted on a first come, first serve basis. Assistance will be granted for a maximum of one year for membership. You can reapply to receive continued assistance. Please read through and fill out the attached application form, again we are unable to process incomplete applications. If you have questions, our membership staff will be happy to assist you. YOU MAY RETURN YOUR COMPLETED APPLICATION WITH SUPPORTING DOCUMENTATION TO: Skagit Valley Family YMCA 215 East Fulton Street Mount Vernon, WA

2 OUR CURRENT MEMBERSHIP RATES FOR FULL-PAY MEMBERSHIPS (These rates are not necessarily applicable to Financial Aid memberships but serve as a guide in our determining how to come to a fee structure for your award) TYPE OF MEMBERSHIP JOINING FEE MONTHLY PAYMENTS BY BANK DRAFT ANNUAL RATE (DOES NOT INCLUDE JOINING FEE) YOUTH (18 & UNDER) $35 $21.00 $ ADULT (19 & OVER) $75 $42.25 $ ONE PARENT FAMILY $85 $53.50 $ TWO PARENT FAMILY $100 $64.00 $ SENIOR (65 & OVER) $70 $38.00 $ SENIOR COUPLE $80 $52.00 $592.80

3 PERSONAL INFORMATION SKAGIT VALLEY FAMILY YMCA SCHOLARSHIP ASSISTANCE APPLICATION READ THROUGH ENTIRE DOCUMENT & PLEASE PRINT ALL INFORMATION AND ANSWER ALL QUESTIONS. BE CERTAIN TO ATTACH REQUIRED DOCUMENTS. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. HEAD OF HOUSEHOLD DATE OF BIRTH TODAY S DATE ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE CELL PHONE EMPLOYER OCCUPATION FULL-TIME PART-TIME UNEMPLOYED DISABLED RETIRED FULL-TIME STUDENT How did you hear about the YMCA Scholarship Assistance Program? PLEASE LIST ALL MEMBERS IN YOUR FAMILY WHO ARE LISTED ON YOUR TAX RETURN NAME First, Middle Initial, Last RELATIONSHIP EMPLOYER/SCHOOL DATE OF BIRTH I AM APPLYING FOR FINANCIAL ASSISTANCE FOR THE FOLLOWING MEMBERSHIP CATEGORY: ADULT ONE ADULT FAMILY TWO ADULT FAMILY YOUTH SENIOR SENIOR COUPLE

4 PERSONAL INFORMATION (CONTINUED) IS THIS A NEW MEMBERSHIP OR RENEWAL? NEW RENEWAL HAVE YOU EVER APPLIED FOR FINANCIAL ASSISTANCE AT THE YMCA BEFORE? IF YES, PLEASE NAME THE YMCA YEAR FINANCIAL INFORMATION PLEASE ITEMIZE YOUR MONTHLY HOUSEHOLD, PRE-TAX INCOME: Gross wages, salary, and tips $ Spouse or Partner s gross wages, salary & tips $ Aid to dependent children $ Unemployment Compensation $ Social Security Disability $ Child Support $ Housing Allowance $ TANF $ Food Stamps $ Retirement Income (Non Social Security) $ Social Security Retirement $ Other Income (Alimony, Interest, Dividends, etc.) $ TOTAL MONTHLY INCOME $ TOTAL MONTHLY MEDICAL EXPENSES $ Please include a monthly fee you feel you would be able to pay for your membership: OFFICE USE ONLY: Scholarship Award $ Amount Due $ Value of Membership $ CONTINUES ON THE NEXT PAGE

5 REQUIRED ATTACHMENTS INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED PLEASE ATTACH THE FOLLOWING (IF THERE ARE 2 ADULTS IN THE HOUSEHOLD, DOCUMENTS NEED TO BE PROVIDED FOR BOTH ADULTS TO VERIFY INCOME INDICATED ABOVE): A letter from you explaining the reason you are applying. If any of the following attachments or documents are not available, please explain in your letter any other means of support you are receiving; for example - living with a family member or friend etc... Please indicate a monthly membership fee you feel you would be able to pay. We ll use this information in helping us determine your final award amount. Most recent Federal Income Tax form. If none filed include reason in the letter and attach W2 or other income source documentation. Most recent pay stubs for one month. If no current income, please explain your means of support. Most recent bank statement. Child support, Alimony Award Statement, Food Stamps, SSI, TANF or other assistance (IF APPLICABLE). Copy of current college class schedule to verify full-time student status (IF APPLICABLE). I,, certify that all the information provided is truthful and a full accurate statement of my household s financial situation. I understand that the YMCA reserves the right to refuse assistance to any applicant. I understand that I will be expected to pay a portion of my membership. If my situation changes, I agree to notify the YMCA within 30 days. If I submit false or inaccurate information, or fail to notify the YMCA within 30 days, I may be terminated from the scholarship assistance program. SIGNATURE DATE