YMCA of Western North Carolina

Financial Assistance Application/Screening Form

Deadline Date: April 16, 2012

(While the deadline is April 16th, we will continue to review these as long as there is funding available. In the event that our
funding is exhausted, we will waitlist eligible applicants in the event that additional funding becomes available.)

Summer Camp 2012

Date________________________________
Parents _____________________________
Hm # _______________________________
Cell # ______________________________
Wk # _______________________________
S/C Site:_____________________________

Childs Name:____________________________
Age:____ Sex: ____ Race: ________ Grade:___
Childs Name: ____________________________
Age: ____ Sex: ____ Race: ________ Grade:___
Childs Name: ____________________________
Age: ____ Sex: ____ Race: ________ Grade:___

As you know, the YMCA is for everyone, and we provide a variety of programs and services for children, adults
and families
Is your child currently in our Afterschool Program? ______ Site: ___________
FINANCIAL INFORMATION
My total Family Income is:
Monthy

$_____________

Annually $______________
Do you receive any of the following? If
so, how much PER MONTH?
AFCD

$____________

Food Stamps $_____________

Child Support $_____________
Social Security $_____________
Pensions

$_____________

Other

$______________

The YMCA does have limited resources available to provide financial assistance, but it is
a requirement that you apply for subsidy first through Buncombe County Child Care
Services. Have you applied for county vouchers?________
In order to qualify for financial assistance for child care, parents must meet the
programs guidelines. Parents must be working full-time (30 or more hours per
week) or enrolled in school full-time.
How many hours per week do you work? _______ your spouse?______
Are you a single parent? _______
Are you a full time student? ________
school schedule.

If so, attach a copy of your full-time

Have you attached copies of your last three paycheck stubs? _________
Have you attached a copy of your 2011 tax return? (1st page only) _______
Amount you could possibly pay per week? _________________
Are you aware there is a registration fee of $35.00 (1)
This amount is not covered by financial assistance.

$50.00 (2+) ? ______

Have you completed the entire Financial Assistance application including the Extenuating Circumstances for
us to consider when reviewing your application? ________
I hereby acknowledge that all of the information provided on this application is true and correct.
_______________________________________
Parent Signature

__________________
Date

Please list any extenuating circumstances for us to consider when reviewing your application:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
If your child has previously received Financial Assistance, how do you feel the program has helped
your child?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I authorize the YMCA to share my story.

Yes

No

As a recipient of a YMCA scholarship

Would you be willing to volunteer during the Annual Fund Raising Campaign?
Would you be willing to volunteer in the Afterschool Program?

Yes

Yes

No

No

If so, in what area would you like to volunteer?

Marketing
Office/Administration
General Site Supervision
Teaching Special Skills
Other ___________________________________________________________
I acknowledge that if I am offered and accept Financial Assistance, I understand that my portion of
the child care program cost must be paid on time and my account must be kept current. Failure to
comply with the payment polices outlined in the program handbook may jeopardize future financial
assistance. Initial ____________
_________________________________
Parents Name

Office Use Only

Previous F.A.____________________
_______________________________
_______________________________
_______________________________
_______________________________

__________________
Date

________________________
________________________
________________________
Child(ren)s Name(s)