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Financial Assistance Form
YMCA
2024-09-10T16:37:08-02:30
Home
Avalon Peninsula Region
Placentia Regional YMCA
Financial Assistance Form
Financial
Assistance Application
Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
I am applying for:
(Required)
Membership
Child Care
Camp
Address
(Required)
Street Address
Address Line 2
City
Postal Code
Phone
(Required)
Email
(Required)
Number of individuals in Household
(Required)
Annual Household Income
(Required)
How much do you think you can pay? (weekly/biweekly/monthly - please specify)
(Required)
Additional Family Members
Name
First
Last
Age
Name
First
Last
Age
Name
First
Last
Age
Name
First
Last
Age
Name
First
Last
Age
Name
First
Last
Age
Name
First
Last
Age
Upload Documents
Documents can be uploaded with your application or brought to the YMCA once you have been contacted for an appointment.
The following documents are needed:
- Most recent Notice of Income Tax Assessment(s) for household family members
- Previous month’s paystub(s)
- Other sources of income (e.g. Child Tax Benefit/Child Care Supplement, rental income, employment insurance, disability/low-income supplement, CPP, OAS, Workers Compensation)
Drop files here or
Select files
Max. file size: 256 MB.
Consent
(Required)
I declare that the information provided is accurate. I am aware that the Y Financial Assistance Program is intended for individuals who are in need and who are unable to afford the full fee. If at any time my financial situation changes and I am able to make a greater contribution, I will contact the YMCA to have my fee adjusted.
I Agree
Applicant's Name
(Required)
First
Last
Δ
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