Financial Assistance Application (Childcare) - YMCA of Central Northern Westchester

First Participant's Name *

First

Last

First Participant's School *

Second Participant's Name *

First

Last

Second Participant's School

If More Than 2 Participants Please List the Names & Schools of Additional Children Below

Program *

Childcare - Infant, Toddler & Preschool,
Childcare - School Age, Academy or White Plains Summer Program

Multiple Choice *

New Application
Renewal

Guardian's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Alternate Phone

Email *

Spouse or Partner's Name *

First

Last

Use NA if none.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Alternate Phone

Marital Status *

Household Information

Please list the Name, Age, Gender and Relation to Guardian for all persons living in the household.

Section Divider

Are you Currently Employed *

How long at current job?

Employer's Name *

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Phone

Is Spouse/Life Partner Currently Employed? *

How long at current job?

Employer's Name *

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Phone

Total 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 For

Amount of Fees I am Able to Pay

I am Requesting Financial Assistance in the Amount of

Please Share Why You are Applying for Financial Assistance *

Upload Paystubs