Financial Assistance Application

Please note: The financial application process for membership is closed until January 2026.

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: *

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

Please itemize your monthly income and expense items

INCOME (please enter numbers only)

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 :

TOTAL MONTHLY INCOME:

EXPENSES (please enter numbers only)

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

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Financial Assistance Application

Family Information:

INCOME (please enter numbers only)

EXPENSES (please enter numbers only)

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