MEMBERSHIP FINANCIAL ASSISTANCE APPLICATION 2025

MONROE COUNTY YMCA 2025 MEMBERSHIP

Financial Assistance Application for a 2025 Membership to the Monroe County YMCA
FOR YOUTH DEVELOPMENT | FOR HEALTHY LIVING | FOR SOCIAL RESPONSIBILITY
Questions? Read our Financial Aid FAQ: Here
FINANCIAL ASSISTANCE APPLICATION
Financial Assistance applications must be completed and submitted online by Saturday, November 30. Applications can also be completed electronically at the kiosk located in the Welcome Center of either our respective branches. Scanned applications sent to us via email will NOT be accepted.

Make sure you have a copy of your necessary documents ready to submit:
- Have a copy of your 2023 Federal Tax Return (Form 1040, pages 1 and 2 only or 1040EZ). Please mark out all Social Security numbers and tax ID numbers.
- Have two consecutive pay stubs for each income-earning member within the household. If you are unemployed, draw social security, or are a full-time student, please provide a summary of your unemployment benefits, SSI paperwork, financial aid benefits, and/or student schedule.
File Upload:*

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Name*

Primary Applicant (Adult) First NameLast Name
Address*

Street or PO Box

Apartment Number

CityState / Province

Zip
Email Address*
Primary Phone*
Primary Applicant Date of Birth*

MonthDayYear
Date
Spouse and Dependents Living at Home

This includes spouse, dependents, or other persons living in the same residence. Please list all household members regardless of their intention to have a membership with the Y. Tax forms must reflect those individuals listed below.

	Name	Relationship	Birthday	Name of School or Workplace	Is this person to be included on your Y membership? If yes, check box.

How many family members are living in the household?*
How many actual dependents are living in the household the primary applicant supports?*
Primary Applicant's Employment*
Number of Hours Per Week*
Full-TimePart-TimeSelf-EmployedSeasonal WorkOther
Spouse/ Other Household Member Employment
Number of Hours Per Week
Full-TimePart-TimeSelf-EmployedSeasonal WorkOther
Please describe your need for financial assistance from the Y (disability, financial hardships, etc.).*
Please check the appropriate membership type for your household (one only):*

Youth (7-18)Young Adult (19-29)Adult (30-64)1 Adult and Dependents*2 Adults2 Adults and Dependents*1 Senior Adult (65+)2 Senior Adults (65+)
*Dependents include those age 21 and younger living in the same household
Please itemize your Gross Monthly Income in the designated lines below. This form will calculate all of the income entered and multiply the value by 12. This is the Total Annual Income recorded in the designated box below.

Monthly Income*

	Primary Applicant	Spouse	Other
Salary, Wages, and Tips
Unemployment Compensations
Child Support
Disability
Social Security Compensations
Aid for Dependent Children (AFDC)
Alimony
WIC
School Loan Income
Housing Allowance
Food Stamps
Other
Total Monthly Income
Total Annual Income

Did you file a Federal Tax Filing for 2023?

YesNo
I hereby give my consent for release of all the above information for consideration for Monroe County YMCA financial assistance. I have attached all required documentation and I understand the documentation will be used to assess my percentage of assistance and what my assessed monthly membership contribution will be.

Financial assistance is only being considered for the 2025 calendar year. A new application must be completed every November in order to be considered for financial assistance for the next calendar year.
Signature of Applicant (Must be 18 or older)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MONROE COUNTY YMCA 2025 MEMBERSHIP

FINANCIAL ASSISTANCE APPLICATION