Membership Scholarship Application Form - James Family Prescott Ymca printable pdf download

Date Rec’d___________

Rec’d by_____________

James Family Prescott YMCA

Membership Scholarship Application

Funds for financial assistance have been made available through the generous contributions of YMCA

friends. Please fill out the following information and attach the necessary documents (photocopies

only) and return to the James Family Prescott YMCA. Balance of the approved allocation will be your

responsibility and must be paid through our automatic monthly bank draft program. Please print all

information. All YMCA members receive the same membership benefits regardless of whether or not

they are receiving financial assistance.

Applications will be processed only after all information is

submitted and application is filled out completely

. Please print legibly.

Name (Head of Household)___________________________________________ Phone(s )____________________________________

Address___________________________________________________ Work Phone_________________________

City_________________________ State________ Zip Code____________ Birthdate________________

Email Address ____________________________________________________________________

Place of Employment__________________________________Position___________________________

 Full Time

 Part Time

Length of Employment_______________________________

Adults / Children Living in Home

Relationship

School/Employer

Birthdate

Age / Grade

____________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

Using the checkboxes above, indicate which household members you wish to include on this membership.

 No

Have you ever applied for scholarship assistance at the James Family Prescott YMCA? Yes

If yes, what was / is your monthly membership payment? _______________

What is the dollar amount that you have the ability to pay each month? $____________ month

Would you be willing to share how your scholarship has made a difference in your life?  Yes

 No

Why are you applying for scholarship assistance? ___________________________________________________________________

____________________________________________________________________________________________________________________________________

OVER

James Family Prescott YMCA

750 Whipple St.

Prescott, AZ 86301

928-445-7221

Membership Scholarship Application Form - James Family Prescott Ymca