Scholarship Form - Ymca
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2Baker County YMCA
3715 Pocahontas Rd.
Baker City, OR 97814
541.523.9622
Scholarship Form
ASSISTANCE INFORMATION
I certify this information is true and complete to the
best of my knowledge. I understand it is my
Financial information is for:
responsibility to notify the YMCA regarding changes
to my financial and/or membership status. I
_____ Youth Membership
understand and agree that the YMCA may make
contact to verify this information. I understand that
_____ Adult/Senior Membership
my financial need may be re-evaluated at any time by
_____ Adult/Senior Couple Membership
the YMCA. I authorize employers and/or other income
sources to release financial information to the YMCA.
_____ 1 Adult + Children
I also understand all information will remain
_____ 2 Adults + Children
confidential.
I understand that when my scholarship is granted, it
_____ Programs
is valid for six months, beginning on the date that it
is processed. I understand that at the end of that six
months, I must re-submit a scholarship application
Are you currently receiving a scholarship
with updated and accurate income information if I
from the YMCA?
would like to continue my membership with a
scholarship.
YES _____ NO _____
Print Name__________________________
Signature____________________________
Adults in household _____
Phone _____________________________
Dependent Children in household_____
Date of Birth ____________
Today’s Date ____________
I am able to contribute $_________ per
INCOME
month for a membership and/or $_________
Monthly gross income from wages $_________
for a program.
Other monthly income (Public
Assistance, Child Support, etc.)
$_________
OFFICE USE ONLY
Total household income last year
$_________
Reviewer _________________
Date _________________
_____ Income Tax Return
MONTHLY EXPENSES
_____ Current Wage Stub
Mortgage/Rent
$__________
_____ Other documentation
Utilities
$__________
Medical Expenses
$__________
Scholarship __________%
Other Expenses
$__________
Date to Reapply _____________
Student Loans
$__________
Draft $______________
Total Monthly Expenses
$__________
Monthly $____________
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