ATHENS YMCA

915 Hawthorne Avenue
Athens, GA 30606

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Financial Assistance Application

Please fill out the following information. Associate Executive Director Jacqueline Shirley will reach out to you for additional documents and information on the process.

First Name: *

Last Name: *

Email: *

Phone: *

Address: *

City: *

State: *

Zip: *

Place of Employment: *

Date of Birth: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

What membership type are you interested in? *
Adult
Family
Family Health Club
Ladie's Health Club
Men's Health Club
Senior
Senior Couple

Family Information:

How many people live in your household?: *

Add all family members that live in the household

Spouse/Child's Name: *

Age: *

School/Employer: *

Birth Date: *

Why do you want financial assistance to the Athens YMCA?*
Job loss
Child suport
Medical bills
Other

Application for financial assistance is for: *
After school Program
Summer Camp
Membership
Other (please state)

Have you ever applied for financial assistance before at the Athens YMCA: *
Yes
No

Present Income Levels Is (Please Check Options): *
Under $8,000
$8,001 to $12,000
$12,001 to $15,000
$15,001 to $18,000
$18,001 to $20,000
$20,001 to $25,000
$25,001 to $30,000
Over $30,000

Please itemize your monthly income and expense items

INCOME

Gross Monthly Income (Before Taxes):

Spouse's Gross Monthly Income (Before Taxes):

Child Support:

Aid to Dependent Children:

Social Security Compensation:

Unemployment Compensation: *

Food Stamps:

Welfare:

Retirement Funds:

Other :

Other (Please Explain):

TOTAL MONTHLY INCOME:

EXPENSE

Rent/Mortgage :

Car/Insurance :

Fuel :

Groceries :

Utilities :

Phone :

Child Support :

Medical :

Child Care :

Alimony :

Other :

TOTAL MONTHLY EXPENSES:

A staff member will contact you for additional documentation. You will be asked to submit verification of the following items (at least 2 out of the 7 items)

Special Expenses
Three most recent payroll stubs including year to date earnings
A copy of last year’s income tax form
A copy of unemployment income
A copy of child support and/or alimony checks
Proof of mortgage or rent payments
Proof of automobile payments(s) (if applicable)

I certify that the information on this application is true and complete to the best of my knowledge. I understand the verification documents must be submitted or my application cannot be processed.

Application's Signature:

Date of Application:

Verification Code