Confidential Application For Scholarship Assistance Form - Family Ymca Of The Glens Falls Area
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2Membership Activation
Date: ___________
Family YMCA of the Glens Falls Area
Confidential Application for Scholarship Assistance
Important Instructions:
• Complete this application and mail into the YMCA: 600 Glen St. Glens Falls NY , 12801 or return to
the front desk in a sealed envelope.
• Enclose in envelope all income documentation that applies to complete application: previous
year’s tax return, current pay stubs, SSI/SSD allocation statement, food stamp
statement, alimony/child support . Assistance will not be awarded if all documentation is not
enclosed.
• Award letter will be mailed to you within 10 business days
• A Government Issued Photo ID must be presented at the time of joining
Please print all information.
Date of Application: _______
_____ New application _____ Membership Renewal application
Name: ______________________ Home Phone: __________________ Work Phone: ________________________
Address: _______________________________ City: _________________ State: ______ Zip: ____________________
Date of birth: _____________
Place of Employment: ____________________ How long have you been employed there? ________________
Please list all persons who live in your household and sh are living expenses or meals
Name/ Relationship
Date of Birth
School/Employer
Total Number in Household __________
PLEASE CIRCLE ONE:
Are you or any member listed on this form on a state or national sexual offender registry?
Yes/No
Are you a single head of household? ___Yes ___ No
If so, ______ Male _______ Female
Ethnicity/Race _____Hispanic/Latino _____American Indian or Alaska Native ______Asian _____ African American
_____Native Hawaiian or other Pacific Islander ______Caucasian______ Other
Financial Assistance Request is for:
____Membership
____Program(s)
___Child Care
____ Camp
____Other: ____________
Please continue on back page
Have you ever applied for scholarship assistance before at the Glens Falls Family YMCA?
____ Yes ____No approximate date of previous assistance _________
What is the dollar amount that you are willing to pay or have the ability to pay each month?
$___________
What benefits do you see in having this scholarship to join the YMCA as a member or participant?
__________________________________________________________________________________________________
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