Piranhas Swim Team Financial Assistance Application

Parent/Guardian First Name

Parent/Guardian Last Name

Primary Phone

Primary Email

Birthdate

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Is this your first time applying or is this a renewal?

New

Renewal

Program Site

First Name

Last Name

Birthdate

Gender

First Name

Last Name

Birthdate

Gender

First Name

Last Name

Birthdate

Gender

First Name

Last Name

Birthdate

Gender

Best Day/Time to Call

Total Household Members

Number of adults/kids living in residence

Wages and Tips

Unemployment (if applicable)

Food Stamps/WIC (if applicable)

Child/Spousal Support (if applicable)

Worker's Compensation (if applicable)

Rental/Utility Assistance (if applicable)

Other (if applicable)

Loans, Grants, Gifts, etc.

Income Source 1

One file only.
128 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Income Source 2

Income Source 3

Do you receive "in-kind support" such as a family member or friend paying for expenses? If so, please explain.

How much can you afford to pay for your program?

Tell us more about your situation and how the Y can help.

Honesty Agreement

I certify that the information included in this application is true and complete to the best of my knowledge, and that I do not have additional income not represented on this form. I agree to provide additional information to support this information, if requested. I understand my Y-Access assistance is based on need. In the event that my situation changes, I will contact the YMCA immediately. I understand that if I falsify this information, I will not be eligible for assistance now and/or in the future.

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