YMCA OF BRISTOL — Financial Assistance Application
The YMCA Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.
Through the generosity of donors to our Annual Giving Campaign, the YMCA is able to provide financial assistance to families with lower incomes and financial hardships who wish to participate in our programs. Every YMCA member receives the same membership benefits, regardless of whether or not they receive financial assistance.
Please complete this form providing proof of all income and assistance you receive and return it to member services for review.
- Are you requesting assistance for a membership or program?
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- City of Residence:
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Primary Adult In Household
- Name — First, Middle, Last
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- Date of Birth
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- Phone Number
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- Are you a college student? — Yes / No
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- If yes, where?
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2nd Adult in Household
- Name — First, Middle, Last
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- Date of Birth
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- Phone Number
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- Are you a college student? — Yes / No
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- If yes, where?
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Dependents
Dependent 1
- Dependent’s Name
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- Date of Birth
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Dependent 2
- Dependent’s Name
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- Date of Birth
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Dependent 3
- Dependent’s Name
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- Date of Birth
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Dependent 4
- Dependent’s Name
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- Date of Birth
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Income – Total Household income before deductions
- 1st Adult (Employment)
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- 2nd Adult (Employment)
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- Social Security Benefits
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- Disability Benefits
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- Unemployment Benefits
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- Food Stamps/SNAP
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- Child Support/Alimony
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- Retirement/Pension
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- Foster Child Support
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- Other Household Income
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- Total Monthly Income
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Expenses – Verification may be required
- Rent or Mortgage
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- Car Payment(s)
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- Student Loan(s)
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- Insurance
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- Utilities
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- Phone
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- Internet/Cable
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- Groceries
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- Additional Expenses
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- Total Monthly Expenses
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- Amount you could pay monthly for the membership type requested $
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- Amount you could pay for each program session requested $
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For Office Use Only
- Staff Initials
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- Date
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- New Applicant / Renewal / Current Member
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Verification Confirmation
- Unemployment
- Social Security
- Disability
- Adult #1 Pay Stubs
- Adult #2 Pay Stubs
- Child Support/Alimony
- Retirement/Pension
- SNAP
- Foster Child Support
- Tax Form
- Other Income:
- Total Income: $
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- Financial Assistance Awarded: %
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- Recipient Pays: $ /month
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- Exp. Date:
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YMCA OF BRISTOL · 400 M L King Jr. Blvd., Bristol TN 37620 · P 423 968 3133 · F 423 968 3618 · W bristolymca.net
YMCA OF BRISTOL — Financial Assistance Agreement
- Primary Member
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- DOB
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Please initial the following:
- I accept and agree that all fees are to be paid on time and prior to program participation for my Financial Assistance to continue.
- I understand that my Membership and/or program participation will discontinue if I acquire a balance owed to the YMCA.
- I hereby certify that the information provided is true and complete to the best of my knowledge.
- I agree to inform the YMCA immediately of any change in the provided information.
- I understand that false information could jeopardize my financial assistance.
- I hereby give my permission to the YMCA of Bristol and its representatives to contact individuals or employers for salary and bill verification.
- I understand that I will be asked to pay a percentage of any membership/program fees.
- I verify that everyone on my membership and Financial Assistance application reside in the same household as the Primary Member. If there are any changes to the status of my household (anyone moves out of or into the household), it is my responsibility to let the YMCA know. Financial Assistance will be re-evaluated at the time of change.
- I understand that Financial Assistance is good for one year from the date of approval unless notified otherwise. When it is time to renew your Financial Assistance, we will notify you. If we do not get a response from our requests for renewal, you will not be allowed to register for addiotional programs until you take care of your renewal.
Failure to report any changes may result in denial and/or termination of Financial Assistance and/or Membership
- Signature of Primary Member (person responsible for membership)
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- Today’s Date
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The YMCA is always in need of volunteers, would you be willing to volunteer?
- Yes
- No
YMCA OF BRISTOL · 400 M L King Jr. Blvd., Bristol TN 37620 · P 423 968 3133 · F 423 968 3618 · W bristolymca.net