Financial Assistance Program Application Form Page 3
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4DOWNTOWN OAKLAND YMCA
Financial Assistance Application
Please complete the entire form, sign, date it, and submit to the Downtown Oakland YMCA. All information is confidential.
Completion of this application does not guarantee approval. Please allow approximately two weeks for processing.
Even if you’re only applying for one membership, PLEASE INCLUDE ALL PERSONS LIVING IN YOUR HOUSEHOLD.
q
Assistance is awarded based on household size. Please check
if the person is applying for membership.
PRIMARY ADULT -
PLEASE PRINT LEGIBLY
q
Do you receive income?
First Name
Last Name
q
Yes
/
/
q
No
Date of Birth
Gender
Address Street
City
State
Zip
(
)
(
)
Email
Cell Phone
Home Phone
SECONDARY ADULT
q
Do you receive income?
First Name
Last Name
q
Yes
/
/
q
No
Date of Birth
Gender
FAMILY MEMBERS
q
/
/
First & Last Name
Date of Birth
Gender
q
/
/
First & Last Name
Date of Birth
Gender
q
/
/
First & Last Name
Date of Birth
Gender
q
/
/
First & Last Name
Date of Birth
Gender
IF YOU ARE APPLYING FOR MEMBERSHIP FOR SOMEONE
Documents that can be used are:
• Current tax return (1040, 1040A, or 1040EZ) listing dependents
UNDER THE AGE OF 18,
one adult must be included on this
• A copy of rental agreement that lists your child(ren)’s name
application and a proof of dependency document is required.
• An official letter with your child(ren)’s name(s) and the address
A birth certificate is not proof of dependency.
that is listed on your financial aid application
FAMILY AND MEMBERSHIP INFORMATION
Are you or any members of your family currently members of this YMCA?
If yes, what kind of member?
q
q
q
q
Yes
No
Facility
Program (12 and under)
FOR STAFF USE ONLY
Staff Member Received
Date
DOWNTOWN OAKLAND YMCA 2350 Broadway, Oakland CA 94612 | 510 451 9622 |
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