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Welcome to Scholarship Services at the 92nd Street Y. Please read the following information
carefully so we can respond to your request.

        The application on the web site is for classes and programs registered for at Sales
         and Customer Service. If you are applying for May or Sixty Plus membership, Goldman
         Center children’s programs (Noar, Nesher, camps, or nursery school), please call
         Scholarship Services, 212.415.5699, for the appropriate application.

        Applications are due at least three weeks before the program start date so we have
         time to review and respond. Please allow extra time if you are applying during a
         holiday period.

        Complete both sides of the application even if you received assistance in the past.

        Please attach copies of all financial documents to your form. All applications should
         include a rent or mortgage receipt as well as the other income information described
         on the application form. If you are submitting more than one application, one set of
         documents is fine. We do not need social security or account numbers so please cross
         them out.

        Program information can be found in the 92nd Street Y catalogs available in the Main
         Lobby or on our web site

        Applications should be returned in person at Customer Service in the main lobby or by

        You may reserve a place in a program with a $25 non-refundable deposit for each
         program when returning your completed application. This must be done at least three
         weeks prior to the program start date. If you do not reserve a place, requests will
         depend on space being available.

        You will be notified about your scholarship by phone or mail. You will then need to
         complete the registration process and pay the balance of your fees as well as
         the order processing fee by the acceptance deadline. We have many requests
         for assistance and will not hold your scholarship past this date.

        If you have any questions or concerns, please call Scholarship Services, 212.415.5699
         or email,

Revised April 2010
                                                                                                FOR OFFICE USE ONLY
                     SCHOLARSHIP APPLICATION                                                    Date Received
                     Please return completed applications to:
                       Scholarship Services, 92nd Street Y
                                                                                                ID #
                             1395 Lexington Avenue
                              New York, NY 10128                                                Notes

                     For more information, call 212.415.5699,
                         or email                                                   Fees

         All applications must include financial documentation.
               Applications are due at least three weeks before
                  the start date of the program requested.                                             Balance

Name                                                                        Birth Date


City, State, Zip

Place of Employment                              Occupation                         How Long?

Home Phone                             Work Phone                              Cell Phone

E-Mail Address

If request is for a child: Child’s Name                                       Birth Date

Name of School                                                                Current Grade

Program Code                                Program Title
Day(s)                    Start Date                     Time                      Fee $
Have you participated in this program previously?                          If so, when

We urge you to plan carefully as all scholarships are partial and you will need to pay the balance of
all program fees.
What are you able to pay for this program?
                                                    (Your application will be returned if an amount is not indicated)

Reason for request (ple ase be spe cific)

Please provide any additional, relevant information, including unique circumstances

Revised April 2010
         All applications must include a rent receipt or maintenance and mortgage statement,
         as w ell as the follow ing documentation of income:
                      1040/1040EZ or other 2009 Tax Return, with all schedules, W-2 and 1099 Forms and
                       current 2010 pay stub
                      Public Assistance verification if applicable
                      Unemployment Insurance verification if applicable and most recent tax return
                      Social Security/SSI Income/ pension verification if applicable
                      School tuition or scholarship statements

ANNUAL INCOME – Gross annual income including all members of household
 Salary/Earnings                                   $
 Alimony and Child Support                         $
 Workers’ Compensation/Unemployment/Disability     $
 Interest, Dividends, Rental, Annuities, Insurance $
 Social Security and/or Pension                    $
 Financial Support from Relatives                  $
 Other (specify)                                   $

                               TOTAL HOUSEHOLD INCOME                     $
What 92nd Street Y Scholarship Assistance have you (or your family) received?

For which other programs this semester are you or your family requesting assistance?

Are you currently unemployed?
Have you been unemployed in the last two years?

Household Members:
                 Name                        Relationship         Age               Occupation

Monthly housing costs (rent or mortgage and maintenance)

If you are paying school tuition for your child, what are your fees?
(Attach any school tuition or scholarship information, if applicable)

If you have scholarship, what amount do you have?

If you have any additional unusually high expenses, please explain

APPLICANT/PARENT SIGNATURE                                                         DATE

Revised April 2010

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