Financial Assistance Application - YMCA of Southeast Ventura County

WELCOME TO ALL
Financial Assistance Application
THE ESSENCE OF THE Y
With a commitment to nurturing the potential of kids, promoting
healthy living and fostering a sense of social responsibility, the
Southeast Ventura County YMCA ensures that every individual has
access to the essentials need to learn, grow and thrive.
EVERYONE IS WELCOME
It is the goal of the YMCA to be affordable to all. The YMCA
desires that no person be turned away because they cannot afford
to pay. Financial assistance is made possible by the generous
support of members, individuals, foundations and businesses
through our Annual Fundraising Campaign.
COMMITTED TO OUR COMMUNITY
Determining assistance amounts is handled by YMCA branches in a
fair and consistent manner. Every YMCA member receives the
same membership benefits, regardless of whether or not they
receive financial assistance. YMCA members can feel confident
knowing that they are a part of an organization that cares greatly
for the well-being of all people, and is committed to youth
development, healthy living and social responsibility.
Financial assistance reduces the cost of membership &
programs; it does not eliminate them.
*Financial assistance is typically granted for 12 months.
The YMCA requires that individuals and families reapply
annually, with updated documentation.
Failure to turn in all required documentation will delay the
application process. No credits / refunds will be given.
If you do not reapply at the time requested, your fees will
revert to full price.
Membership & program fees are subject to change with a
30 day written notice.
*Some Programs may be approved for less than 12 months
www.sevymca.org
CONEJO VALLEY YMCA
Serving Thousand Oaks,
Moorpark, and Santa Rosa Valley
4031 N. Moorpark Road
Thousand Oaks, CA 91360
Phone: 805.523.7613
Fax: 805.523.8831
info@conejoymca.org
MILLER FAMILY YMCA
Serving Newbury Park
320 Via Las Brisas
Newbury Park, CA 91320
Phone: 805.480.0309
Fax: 805.480.0319
info@millerymca.org
SIMI VALLEY YMCA
Serving Simi Valley
3200 Cochran Street
Simi Valley, CA 93063
Phone: 805.583.5338
Fax: 805.583.5476
info@simiymca.org
TRIUNFO YMCA
Serving Agoura Hills,
Westlake Village, and Oak Park
31225 La Baya Drive. Suite #106
Westlake Village, CA 91362
Phone: 818.707.9622
Fax: 818.706.0282
info@triunfoymca.org
Please contact your branch if you have any questions.

Financial Assistance Application
Apply in 5 easy steps!
1
◦ This is my first time applying
APPLICANT INFORMATION ◦ This is a renewal
2
ALL PERSONS LIVING IN THIS HOUSEHOLD
Adult’s Name
Place a check mark for each family member applying for assistance.
Address
◦ Name
DOB
City
◦ Name
DOB
State
Zip Code
◦ Name
DOB
Home Phone ( )
◦ Name
DOB
Cell Phone ( )
◦ Name
DOB
E-Mail
◦ Name
DOB
DOB
3
Check each category for
which you are applying
FACILITY MEMBERSHIP
SWIM LESSONS / SWIM TEAM
YOUTH CLASSES
SPORTS
I AM APPLYING FOR
FAMILY PROGRAMS - Adv. Guides
TEEN PROGRAMS - MLC / MUN
Office Use
%
Office Use
Expiration
Date
4
TO QUALIFY FOR FINANCIAL ASSISTANCE,
PROVIDE COPIES OF THE FOLLOWING DOCUMENTS
I FILED FEDERAL TAXES
FOR LAST YEAR
◦ 1040 Federal Tax Form(s)
for all incomes in household
◦ I am an individual filing jointly;
I am providing ONE 1040 form
OR
I DID NOT FILE FEDERAL TAXES
FOR LAST YEAR or
MY HOUSEHOLD INCOME HAS CHANGED
SINCE I FILED TAXES FOR LAST YEAR
◦ Documents showing most recent
30 days of income (including
pay stubs or documentation
of government assistance)
CHILD CARE
Parent1 ◦ Home ◦ Work ◦ School
Parent2 ◦ Home ◦ Work ◦ School
◦ We filed more than ONE tax form
in our household; We are providing
_______1040 forms
$ ___________________________ X 12 =
30 DAYS INCOME MONTHS
BASE CAMP
Parent1 ◦ Home ◦ Work ◦ School
Parent2 ◦ Home ◦ Work ◦ School
$ __________________________________
TOTAL ANNUAL HOSEHOLD INCOME
THIS APPLICATION MUST BE RENEWED EVERY 12 MONTHS!
$ __________________________________
TOTAL ANNUAL HOSEHOLD INCOME
TRAVEL CAMP
Parent1 ◦ Home ◦ Work ◦ School
Parent2 ◦ Home ◦ Work ◦ School
AWAY CAMP
OTHER
I certify that the above information is true and complete to the best of my knowledge, and that I do not have
additional income not represented above. I agree, if necessary, to send additional information and
documentation to support the above statements. I understand that financial assistance is based on need. In
the event that I or my children must cancel our participation, I will contact the YMCA immediately so
financial assistance can be provided to others. I understand that if I falsify any of the above information, I
will not be eligible for assistance now and/or in the future.
5
_____________________________________________________________________________________
Signature of person completing this form
Date
Attach all applicable financial documents and turn in to your YMCA branch Member Services Center.
FOR OFFICE USE
TRACKING SHEET: YES NO DAXKO: YES NO
TELL US MORE...Use this space to include any additional information or extenuating circumstances that were
not included on this application. If you need more space, attach and additional sheet of paper.
I want/need YMCA Financial assistance because:
DIRECTOR 1:_________________________________________________________
DIRECTOR 2: ________________________________________________________
NOTES: _______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________