Membership Scholarship Application Form - James Family Prescott Ymca Page 2
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2Income and expenses should be declared for all those occupants who contribute to or are dependent
upon your household. Attach copies for all income and supply a copy of your monthly bank statement
for your expenses and copies of all expenses not paid through your bank account. All financial
information will remain confidential and will be shredded once your application has been processed.
Gross Monthly Household Income
Monthly Household Expenses
Wages, Salaries, and tips (1
st
adult) $________
Rent/Mortgage (circle)$_______
Wages, Salaries, and tips (2nd adult)$________
Car Payment
$_______
Wages, Salaries, and tips (3rd adult) $________
Car Insurance
$_______
Unemployment compensation(1
st
)
$________
Utilities
$_______
Unemployment compensation (2
nd
) $________
Alimony
$_______
Social Security compensation
$________
Phone/Cable
$_______
Disability Compensation
$________
Cell Phone
$_______
Child Support
$________
Clothing
$_______
Aid to dependent Children
$________
Food
$_______
Food Stamps
$________
Child Support
$_______
401k/retirement funds
$________
Medical
$_______
Alimony
$________
Childcare
$_______
$______
Other
$________
Other
Other
$________
Total Monthly Income
$_______
Total Expenses
$_______
Total Annual Income
$_______
I verify that all of the information submitted is correct and accurate.
I understand that most scholarships are in effect for 12 months and that I must reapply to continue
receiving financial assistance.
I understand that it may take up to 2 weeks to process a fully completed application.
I understand that an incomplete application will delay the process.
I understand that the YMCA’s financial assistance has been made through generous contributions of
YMCA members, staff, supporters and friends.
If any situation changes, I agree to notify the YMCA within 30 days.
If I submit false or inaccurate information, my membership may be terminated from the YMCA.
__________________________________________
________________________
Signature of Applicant
Date
************YMCA OFFICE USE ONLY************
Application Reviewed By________________________ Date Reviewed _________________
New Applicant
Renewal
Membership Type__________
Membership Amount_____________
Joining Fee____________
Membership Scholarship ____________
Joining Fee Scholarship _____________
Member Obligation__________
Joining Fee Obligation_____________
Expiration Date ___________
Notified by____________________ Date___________
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