Financial Assistance Program Application Form

Income/Expense Worksheet

(Please print clearly.)

Income:

Expenses:

$ _______________ 1) Your Gross Monthly Income

$ _______________ 1)

Rent

Mortgage

$ _______________ 2) Spouse’s Gross Monthly Income

$ _______________ 2) Auto Loan

$ _______________ 3) Child Support

$ _______________ 3) Utilities

$ _______________ 4) Aid to Dependent Children

$ _______________ 4) Phone listed in your name

$ _______________ 5) Welfare

$ _______________ 5) Child Support

$ _______________ 6) Food Stamps

$ _______________ 6) Medical

$ _______________ 7) Interest Income from Investments

$ _______________ 7) Child Care

Yes

No 8) Reduced Lunch Program (submit card)

$ _______________ 8) School Tuition

$ _______________ 9) Other (please explain below)

Are you paid weekly, biweekly, twice a month or monthly? _______

$ _______________ Total Gross Monthly Income (household)

$______ Total Monthly Expenses

$ _______________ Total Gross Yearly Income (household)

Do you share expenses with anyone else living in your household?

Yes

What is the total number of persons living in your house? __________

How much can you afford to pay per month? $____________________

What is your reason for applying for Financial Assistance?_______________________________________________________

__________________________________________________________________________________________________________

Dear Scholarship Applicant,

__________________________________________________________________________________________________________

Thank you for considering the YMCA to serve your family. The YMCA of Metropolitan Chattanooga is a not-for-profit

health and human services organization committed to helping people grow in spirit, mind and body. The YMCA is here

to serve people of all ages, backgrounds, abilities and incomes. We are community-based and believe that our programs

Scholarship Agreement

and services should be available to everyone. That’s why the YMCA offers a Financial Assistance Program for those who

financially qualify.

I accept and agree that all fees are to be paid on time and prior to program participation for my assistance to continue.

Assistance will be granted for up to six-months. The YMCA requires that individuals reapply after this time period or

Further, I understand that my assistance will discontinue if I acquire a balance owed to the YMCA for a program.

whenever requested to keep the information on file up-to-date. Fees are subject to increase when you reapply. If you do

I hereby certify that the above information is true and complete to the best of my knowledge. I agree to inform the

not reapply when requested, your enrollment will be terminated.

YMCA immediately of any change in the above information. I understand that false information could jeopardize my

Volunteers in the YMCA raise funds for our Strong Kids Campaign. Funds are used for providing financial aid to youth

financial assistance. I hereby give my permission to the YMCA of Metropolitan Chattanooga and its representatives to

and families who need financial assistance. Providing funding to our community is subject to the availability of funds

contact individuals or employers for salary and bill verification. In order to maximize what the YMCA of Metropolitan

collected in the Strong Kids Campaign. The review process for granting Financial Assistance will be handled on a YMCA

Chattanooga is able to offer, I understand that I will be asked to pay a percentage of any membership/program fee.

by location basis.

The process for applying for a scholarship is as follows:

Signature: _______________________________________________________________________Date: ___________________

1) Fill out the scholarship application and worksheet completely.

2) Attach your completed membership application or program registration form.

Cleveland Family YMCA

North Georgia Community YMCA

220 Urbane Road, NE • Cleveland, TN 37312 • 423.476.5573

144 Catoosa Circle • Ringgold, GA 30736 • 706.935.2226

3) Attach a copy of your most recent income tax return, two most recent pay stubs, verification of any other financial aid

Downtown Family YMCA

North River Family YMCA & Aquatic Center

(free lunch program, AFCD, etc.) for income verification. Single parent families (divorced) may attach a copy of their

301 West Sixth Street • Chattanooga, TN 37402 • 423.266.3766

4138 Hixson Pike • Chattanooga, TN 37415 • 423.877.3517

Child Support Obligation Worksheet. Note: Your application cannot be processed without income verification.

Hamilton Family YMCA

Rhea Family YMCA

4) Return the completed application to the YMCA front desk.

7430 Shallowford Road • Chattanooga, TN 37421 • 423.899.1721

232 Fourth Ave., #7 • Dayton, TN 37321 • 423.775.0821

James A. Henry Community YMCA

YMCA Camp Ocoee

5) You will receive a verification letter in the mail indicating the terms of your scholarship.

301 West Sixth Street • Chattanooga, TN 37402 • 423.266.4844

111 YMCA Drive • Ocoee, TN 37361 • 423.338.5588

You must redeem your scholarship within 3 - 4 days of acceptance.

Financial Assistance Program Application Form - Ymca

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