The Mason City Family YMCA welcomes all who wish to participate and believes no one should be denied access to the YMCA based on on their ability to pay. With a commitment to nurturing the potential of kids, promoting healthy living and fostering a sense of social responsibility, the YMCA ensures every individual has access to the essentials needed to learn, grow and thrive. Primary Applicant First Name(required) Primary Applicant Last Name(required) Birthdate (MM/DD/YYYY)(required) Email(required) Phone Number(required) What membership type are you applying for?(required) Youth Adult Couple Single Parent Household Family Have you had membership financial assistance with the YMCA before??(required) Yes No I'm not sure. Allow email?(required) Yes No Allow SMS texting?(required) Yes No Secondary Applicant First Name Secondary Applicant First Name Birthdate (MM/DD/YYYY) Email Phone Number Child 1 (Name and Birthday) Child 2 (Name and Birthday) Child 3 (Name and Birthday) Child 4 (Name and Birthday) If more than 4 children live in your home, select below More than 4 children live in my home. STEP 2 Address(required) City(required) State(required) Zip Code(required) STEP 3 Emergency Contact(required) Emergency Contact Phone Number(required) STEP 4 While financial information is important for the decision and level of financial assistance, past and current financial information is not the only determination for financial assistance. Please fill out the below forms accurately and to the best of your ability. Monthly income from wages, social security income, disability, child support, food stamps, alimony, etc(required) How will you/your family benefit from a YMCA membership?(required) Is there anything else you would like us to know? I agree to provide one of the following forms for each adult in the household. 1040/1040EX tax document for the most recent year, Social Security Benefit statement, or 3 most recent pay stubs. Email to cnelson@masoncityymca.org or drop off at the YMCA 1840 S. Monroe, Mason City(required) Yes CONSENT AND RELEASE I agree that the Mason City Family YMCA shall not be responsible for any personal injuries or losses sustained by me or my family while on any Y premises, or as a result of any Y sponsored activities. I further agree to indemnify and hold harmless the Ymca. I agree to the above consent and release.(required) Yes SUBMIT Δ
