Child Care Financial Assistance Application Form

CHILD CARE FINANCIAL ASSISTANCE APPLICATION

This application is not to be considered as a guarantee of financial assistance. Please print the information requested.

Current proof of income must be attached for consideration.

Please check the financial assistance area you are applying for:

SCHOOL AGE CHILD CARE: AGES 5-13

PRESCHOOL: AGES 2-5

❑ After School Age Child Care

❑ Summer Day Camp

❑ Full Day Preschool

❑ Before School Age Child Care

❑ Schools Out Day Camp

❑ Preschool Enrichment

❑ Late Start School Age Child Care

YMCA Child Care location or school child would attend ______________________________________________________________________________________________________________

Date ______________________________________________________________________________

Parent/Guardian First Name ______________________________________________

MI ________ Last Name ________________________________________________________________

Home Street Address _______________________________________________________ City ________________________________________________ State _________ Zip ____________

Home Phone __________________________________________________________________ Cell Phone ________________________________________________________________________________

Email ______________________________________________________________________________________________________________________________________________________________________________

DOCUMENTATION OF INCOME

Please provide all information required. Your request will not be processed without providing proof of your total household income.

Total monthly gross income for entire household $ _____________________

(Include proof of income for ALL household members, including child support, social security, public assistance/food stamps,

state and federal aid, unemployment, etc.)

Please attach copies of the following:

❑ Two most recent paycheck stubs for all working individuals

❑ Federal IRS tax return for most recent tax year

❑ Social Security income verification letter

(1040,1040A,1040EZ)

❑ Public Assistance income verification letter

❑ W2 check stubs/forms