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					 How to Use This Form                                   YMCA of Austin

1. Complete the YMCA of Austin Financial As-
                                                   Financial Assistance Policy                   The
                                                                                                 YMCA
                                                  YMCA of Austin programs and activities are
   sistance Application on the reverse side of    designed to benefit persons of all back-
   this brochure.                                 grounds, and fees are based on the cost of
2. Attach one of the following additional

                                                                                                 is for
                                                  providing each program. While partici-
   forms to the application:                      pants are expected to pay their fair share,
    · Your most recent 1040 Federal tax return,   when financial assistance dollars are avail-
      or

                                                                                                 everyone
                                                  able, the YMCA will assist any individual
    · Your two most recent pay stubs or bank      or family that wants to participate but can-
      statements, and (if applicable)             not afford the fee.
    · The two most recent pay stubs or bank                  East Communities YMCA
      statements of all other earners in your                    5315 Ed Bluestein
      household, and




                                                                                                              YMCA
                                                                     933-9622
    · Proof of other income (including gov-                Hays Communities Family YMCA
      ernment assistance).                                    465 Buda Sportsplex Dr.
3. Return all of the above materials (includ-                     Buda, TX 78610
                                                                     523-0099
   ing this form) to the appropriate YMCA of
   Austin branch.                                            North Park Family YMCA              Financial
                                                                9616 North Lamar
                                                                    973-9622                     Assistance
          What Happens Next                                                                      Program
                                                             Northwest Family YMCA
                                                                  5807 McNeil
1. Processing of your forms usually takes about                     335-9622
   two weeks.
2. When your forms are processed, the YMCA                   Pflugerville Center YMCA
   will contact you by letter or telephone.                   15808 Windermere Drive
                                                                     928-9622
3. The YMCA will send you a letter to verify
   that your application has been approved.                  Program Services YMCA
4. Bring the verification letter with you when-               2121 E. Sixth St. Ste 203
                                                                     236-9622
   ever you sign up for a YMCA membership
   or program.                                               Southwest Family YMCA
                                                                  6219 Oakclaire
  Financial Assistance Is Temporary                                  891-9622
                                                               Springs Family YMCA
                                                            27216 Ranch Road 12 South
The YMCA of Austin recognizes that from                     Dripping Springs, TX 78620
time to time, people may need some finan-                            894-1789
cial help. Financial assistance is intended to                  TownLake YMCA
be temporary. You may be asked to reapply.                    1100 West Cesar Chavez
                                                                    542-9622
         YMCA of Austin -- Financial Assistance Application
            Application must be filled out completely. Please print clearly and include all required paperwork listed with this form.

Applicant Information               I am applying for: Membership Fitness Aquatics Afterschool Camp                                (Circle all that apply)
Last Name:                                                  First Name:                                                              Home Phone:

Address:                                                                                                                              Apt #:

City:                                                           State:                                                                Zip:

Email Address:

Employer:                                                       Employment Status:                                                    Work Phone:
                                                                Full or Part time
Hourly Wage: $                                                  Annual Income: $                                                      # of Dependents
                                                                                                                                      All persons living in household

                      List the Names and Ages of all dependents, children and adults living in your household:

        Name:______________________ Age: _______                                                   Name:______________________ Age: _______

        Name:______________________ Age: _______                                                   Name:______________________ Age: _______

Spouse or Other Wage Earner Information
Last Name:                                                      First Name:                                                           Home Phone:
                                                                                                                                      If different than above
Employer:                                                       Employment Status:                                                    Work Phone:
                                                                Full or Part time
Hourly Wage: $                                                  Annual Income: $

                                  Monthly Family Income:                                          Monthy Family Expenses:                             Staff Use Only

   Household Wages:                                                   Rent/Mortage:                                                   Total Monthly Income: $____________

        Worker' Comp:                                                        Food:                                                    Total Monthly Expense: $___________

        Food Stamps:                                                  Transportation:                                                 Membership Schedule %: _________%

        Child Support:                                                   Child Care:                                                  Program Schedule %: ____________%

    All Other Income:                                                      Medical:                                                   Branch or Site:____________________

        Unemployment:                                                       Utilities                                                 Program Name:___________________

 Social Security or SSI:                                                   All Other                                                  Other Info:________________________
                                                                        (Credit Debt, Ect.):

            Total                                                             Total                                                   ___________________________


Amount I can pay toward this program. $______________________ Must be completed. All applicants asked pay their fair share.

Have You Ever been a YMCA member: YES ___ NO ___ Which Branch?

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 of Applicant: (Parent or Guardian if under 18)                                        Date Application Submitted:

                                                 See attached Applicaton Guidelines for instructions
for YMCA use only              Value of Service: $ _________           Membership Fitness Aquatics Afterschool Camp
                                                                Membershp Type:                Women      Men     Family       Joining Fee (Circle all that apply)

Percent of Assistance: %                   Amount of Assistance: $            Percent Participant Pays: $                     Amount Participant Pays: $

Y Ware ID:                            PCS Code:                                     Branch:                                     Review Date:

Application Reviewed by:                   Date Application Approved:                          Date Applicant Contacted:                Deadline Date:
 Como utilizar este formulario:                                     YMCA de Austin
1. Complete la Solicitud para Asistencia Economica
   de la YMCA de Austin en el otro lado de esta pagina
                                                                  Asistencia Economica
                                                         Programa de Cuidado Infantil despues de la Escuela        El
2. Anada copias de los siguientes documentos a la
   solicitud:
        Su mas reciente Federal Tax Return
                                                         Intencion de la Asistencia Economica: Los progra-
                                                         mas de la YMCA de Austin estan destinados para
                                                         beneficiar a gente de todo origen, clase o cultura.
                                                                                                                   YMCA
                                                                                                                   es para
    •
        (form 1040)                                      Aunque se espera que todos los participantes
                                                         paguen la totalidad de sus cuotas por servicios
    •   Sus dos mas recientes recibos de pago de         prestados por YMCA, asistencia economica puede
        sueldo o informes bancarios

                                                                                                                   todos
                                                         estar disponible para que cualquier familia o individ-
    •   Los dos mas recientes recibos de pago            uo que desea participar pero que tendria dificultad
        de sueldo o informes bancarios de todas          para alcanzar a pagar la cuota completa.
        otras personas en su hogar que perciben
        ingresos                                                      East Communities YMCA
    •   Certificacion de otros ingresos (incluyendo                       5315 Ed Bluestein
        asistencia que recibe del Gobierno)                                   933-9622
3. Entregue todos esos documentos, incluyendo                      Hays Communities Family YMCA




                                                                                                                              YMCA
   esta forma, al local del YMCA apropiado.                           465 Buda Sportsplex Dr.
                                                                          Buda, TX 78610
                                                                             523-0099
                                                                     North Park Family YMCA                       Forma
            Que ocurre luego                                            9616 North Lamar
1. Procesar su solicitud demora unas dos semanas
                                                                            973-9622                              de Asistencia
                                                                      Northwest Family YMCA                       Economica
2. Se le contactara por telefono cuando su solicitud                       5807 McNeil
   sea procesada                                                             335-9622
3. La YMCA le enviara una carta dando fe que su                      Pflugerville Center YMCA
   solicitud ha sido aprobada                                         15808 Windermere Drive
                                                                             928-9622
4. Traiga esta carta de verificacion cuando se
   registre como miembro o para programas                             Program Services YMCA
   de la YMCA                                                          2121 E. Sixth St. Ste 203
                                                                              236-9622

                                                                      Southwest Family YMCA
                                                                           6219 Oakclaire
La Asistencia Economica es Temporal                                           891-9622
YMCA de Austin reconoce que de tiempo en tiem                           Springs Family YMCA
po la gente necesita alguna ayuda. La asistencia                     27216 Ranch Road 12 South
economica es temporal. Se le pedira renovar su                       Dripping Springs, TX 78620
solicitud cada seis meses o cuando se inscriba en                             894-1789
otros programas.                                                         TownLake YMCA
                                                                       1100 West Cesar Chavez
                                                                             542-9622
                                YMCA de Austin – Solicitud de Asistencia Economica
 La solicitud debe ser llenada integramente. Por favor escriba claramente e incluya toda la documentacion indicada con este formulario – ver atras


Informacion del solicitante                     Solicitud para: nuevo miembro               Natación        Gimnasio         Cuidado de niños despues de classes            Campamento


Apellido:                                             Nombre:                                                                        Telefono:

Direccion:                                                                                                                           Apt:

Ciudad:                                                         Estado:                                                              Zip:

Dirección de correo electrónico:

Trabaja en:                                                     tiempo completo                tiempo parcial                        Telefono trabajo:

Salario por hora       $                                        Ingreso annual        $                                              numero de personas que viven en su hogar:

Indique nombres y edad de todos quienes viven en su hogar aparte de usted
                                                                                                Nombre ______________________________                    Edad ___________

Nombre ______________________________                   Edad ___________
                                                                                                Nombre ______________________________                    Edad ___________

Nombre ______________________________                   Edad ___________
                                                                                                Nombre ______________________________                    Edad ___________

Apellido:                                             Nombre:                                                                        Telefono:

Trabaja en                                                                     tiempo completo             tiempo parcial            Telefono de trabajo

Salario por hora       $                                                  Ingreso annual        $                                    Numero de personas que viven en su hogar _____


                                Ingreso mensual de la                                                         Gastos Mensuales                 Para uso interno – no escriba aqui
                                            familia                                                                                           Total Monthly Income_______________________

                 Sueldos                                                          Alquiler / Hipoteca                                         Total Monthly Expense _____________________

          Workers Comp                                                                       Alimentos                                        Membership Schedule ____________________%

            Food Stamps                                                                     Transporte                                        Program Schedule _______________________%

   Concesion de divorce                                                              Cuidado Infantil                                         Branch or Site____________________________

          Otros ingresos                                                            Gastos Medicos                                            Program Name____________________________


              Desempleo                                                     Servicios(agua,luz,etc…)                                          Other Info________________________________


            Seguro Social                                                              Otros gastos                                           ________________________________________


                    Total   $                                                                    Total    $

Suma que puedo pagar para este programa $ ________________ Se ruega a todo solicitante pagar todo lo que pueda

Ha sido Ud. miembro de la YMCA         Si                No                    Donde? _______________________________________________________________________________


Por que desea ser un miembro de la YMCA o participar en alguno de sus programas?




Indique aquellas circunstancias que Ud. considera deben ser tomadas en cuenta cuando su solicitud sea evaluada




Firma del solicitante (o padre o tutor si menor de 18)               Fecha en que la solicitud ha sido entregada


  Para uso interno solamente – no escriba aqui                                      Membership                            Program                    Camp

                      Value of Service $ ___________                                Membership type        Women                    Men              Family           Joining Fee

Percent of assistance               % Amount of assistance $                               Percent participant pays                         % Amount participant pays $

DAXKO Master ID:                               Revenue Account Code:                                            Branch:                                      Review Date:

Application reviewed by                       Date application Approved                             Date Applicant Contacted                        Deadline Date

				
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