YMCA of Austin: Membership

Membership

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Financial Assistance Program
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APPLICANT INFORMATION
*Required Information
Last Name:*	First Name:*
I am applying for:* Membership Fitness Aquatics Afterschool
Address:*
City:*	State:*	Zip:*
Home Phone:*	Other Phone:
Email Address:*
Employer:*	Work Phone:*
Employment Status:*	Hourly Wage:*	$
	Annual Income:*	$

DEPENDENT INFORMATION
*Required Information
# of Dependents:* (all persons living in household)

SPOUSE OR OTHER WAGE EARNER INFORMATION
*Required Information
Last Name:	First Name:
Home Phone:	Other Phone:
Employer:	Work Phone:
Employment Status:	Hourly Wage:	$
	Annual Income:	$

FINANCIAL INFORMATION
*Required Information
Monthly Family Income		Monthly Family Expenses
Household Wages *	$	Rent/Mortgage *	$
Worker' Comp *	$	Food *	$
Food Stamps *	$	Transportation *	$
Child Support *	$	Child Care *	$
Unemployment *	$	Medical *	$
Social Security or SSI *	$	Utilities *	$
All Other Income *	$	All Other Expense *	$
Total Income:*	$	Total Expense:*	$
Amount I can pay toward this program:* $ Must be completed. All applicants asked pay their fair share
Have you ever been a YMCA member:*
Which YMCA of Austin branch would you like to apply for?:
Why do you want to participate as a YMCA member or program participant?*
List special circumstances that you feel should be taken into consideration during review of this application?
Signature:*
* I understand my Financial Assistance Application will not be processed until the YMCA of Austin recieves the following forms for verification: Most recent 1040 Federal Tax Return or Two most recent pay stubs or bank statements, and (if applicable) Two most recent pay stubs or bank statements of all other earners in your household, and Proof of other income (including governmnent assistance)

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