Please enable JavaScript in your browser to complete this form. - Step 1 of 2First Participant's Name *FirstLastFirst Participant's School *Second Participant's Name *FirstLastSecond Participant's SchoolIf More Than 2 Participants Please List the Names & Schools of Additional Children BelowProgram *Childcare - Infant, Toddler & Preschool,Childcare - School Age, Academy or White Plains Summer ProgramMultiple Choice *New ApplicationRenewalGuardian's Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Alternate PhoneEmail *Spouse or Partner's Name *FirstLastUse NA if none.AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell PhoneAlternate PhoneEmailMarital Status *SingleMarried Domestic PartnershipDivorcedWidowedHousehold InformationPlease list the Name, Age, Gender and Relation to Guardian for all persons living in the household.Section DividerAre you Currently Employed *YesNoHow long at current job?Employer's Name *Employer's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer's PhoneIs Spouse/Life Partner Currently Employed? *YesNoHow long at current job?Employer's Name *Employer's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer's PhoneNextTotal Monthly Household Income *Wages, Tips, Salaries, Spouse Wages, Tips, Salaries, Unemployment, SS, Retirement, Pension, Worker’s Compensation, Disability, DSS Title XX or other aid, Food stamps, HUB or Section 8, SSI, Medicaid or Medicare, Child Support & Other Income Total Household Expenses *Housing (Rent/Mortgage), Gas/Electric/Oil, Cable/Phone/Internet, Car Payment/Insurance, Food, Clothing, Student Loans, Child Support, Child Care or other expenses. Total Cost of Program Signing Up ForAmount of Fees I am Able to PayI am Requesting Financial Assistance in the Amount ofPlease Share Why You are Applying for Financial Assistance *Upload Paystubs Click or drag a file to this area to upload. At least four weeks of current wage stubs or 8 weeks if your pay varies from week to week. If no wage stub is available, salary verification from employer. If You Are Self-Employed - You must submit your latest business & personal Income Tax return.Upload Tax Return (IRS form 1040) Click or drag a file to this area to upload. A copy of your most recent Income Tax Return (IRS form 1040) with copies of all supporting W-2 forms.Upload Assistance Letter (DSS, NYS OCFS Funds, Title XX, Food Stamps, HUB or Section 8, SSI, Medicaid or Medicare) Click or drag a file to this area to upload. Copy of award letter.Upload Unemployment, Social Security, Workman's Compensation or Disability Click or drag a file to this area to upload. State Documentation. Current monthly pay stub. Provide name and phone number of the employer that are you Unemployed, receiving Workman’s Compensation or Disabled from.Upload Child Support Enforcement Statement Click or drag a file to this area to upload. Upload Bills Click or drag a file to this area to upload. Monthly bills for three previous months (Housing, phone, utility etc.) to serve as backup to your claim of inability to pay full feesSection DividerAre You Able to VolunteerYesNoVolunteers are an essential part of the YMCA. Without the help of volunteers we would not be able to offer the range of quality programs that are available today. We would appreciate any time you would be willing to give of yourself in volunteering for a program or activity. This has no bearing on your approval of assistance.Ethnicity (Not Required)CaucasianLatino/HispanicAfrican AmericanAsian/Pacific IslanderNative AmericanOtherApplicants are not required to answer, gathered for tracking purposes only. If you choose, answer below.Verification of Information - I attest that all the information on this Financial Assistance form is truthful and accurate, and that all income is reported. I understand that false information or deception on my part would result in denial of assistance. I also understand that should my financial situation change, that I would notify the YMCA Branch. *Please print your full name and date in the box above.Submit