FINANCIAL ASSISTANCE / SCHOLARSHIP APPLICATION

Thank you for your response. ✨

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 children, promoting healthy living and fostering a sense of social responsibility, and connection the YMCA ensures every individual has access to the essentials needed to learn, grow and thrive.

Primary Adult Applicant First Name

Primary Adult Applicant Last Name

Birthdate (MM/DD/YYYY)

Phone Number

What membership type are you applying for?

Have you had membership financial assistance with the YMCA before??

Allow email?

Allow SMS texting?

Secondary Adult Applicant First Name

Secondary Adult Applicant Last Name

Birthdate (MM/DD/YYYY)

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

4+ children

STEP 2

Address

City

State

Zip Code

STEP 3

Emergency Contact

Emergency Contact Phone Number

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

How will you/your family benefit from a YMCA membership?

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, verification of SNAP benefits or 3 most recent pay stubs.
*Email to lhardy@masoncityymca.org or drop off at the YMCA 1840 S. Monroe, Mason City(required)

Yes

CONSENT AND RELEASE

I agree to the above consent and release.(required)

Yes