Financial Assistance Application – Greater Scranton YMCA

Please fill out this form completely. Applications must be submitted with all required documentation. Incomplete applications cannot be processed until all documentation is turned in.

If you need assistance please call the Y at 570-342-8115. If this form is not loading please download the paper application and return to the Y. (Financial Assistance Application)

First Name

Middle Initial

Last Name

Phone Number

Street Address

City, State, ZIP

Date of Birth

Number of Adults

Number of Children

Financial Aid Request Type

Membership & Programs Child Care & Camp

Second Adult First Name

Second Adult Middle Initial

Second Adult Last Name

Second Adult DOB

Second Adult Gender

Child #1 First Name

Child #1 Middle Initial

Child #1 Last Name

Child #1 DOB

Child #1 Gender

Child #2 First Name

Child #2 Middle Initial

Child #2 Last Name

Child #2 DOB

Child #2 Gender

Child #3 First Name

Child #3 Middle Initial

Child #3 Last Name

Child #3 DOB

Child #3 Gender

Child #4 First Name

Child #4 Middle Initial

Child #4 Last Name

Child #4 DOB

Child #4 Gender

Child #5 First Name

Child #5 Middle Initial

Child #5 Last Name

Child #5 DOB

Child #5 Gender

How will the Y's Financial Assistance Program benefit you/your family?

Gross Annual Income

Income Verification Upload - Please upload ALL documentation to support your gross annual income. Documents include but not limited to: 2 most recent paystubs, most recently filed tax return, unemployment, social security, disability, and any other paperwork verifying income.

Acceptance & Verification

I certify that this information is true and complete to teh best of my knowledge. I grant permission to the YMCA to verify this information. I agree to notify the YMCA if my financial status changes.

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