APPLICATION FOR SCHOLARSHIP ASSISTANCE

Applications must contain financial documentation for all members of the household. this may be a copy of a W-2 form, Social Security Statement, Tax Return or paycheck stub. Failure to provide the appropriate financial information will result in notificiation that the application is incomplete.

Please fill out the following information and attach the necessary documents and return to Laura Cowher at the Business Office of the Greater Pittston YMCA. The Business Office is open Monday through Friday from 9 a.m. to 5 p.m.

Financial Assistance awards are based on the entire household income and number of individuals in the household.

Although the Greater Pittston YMCA strives to never turn anyone away for the inability to pay, there are a limited number of funds available. Awards are made on a first come, first serve basis. Please allow two weeks for your application to process.

For more information, call Laura Cowher at 570-655-2255 ext. 103 or email at lcowher@greaterpittstonymca.org.

Date of Application: ___________ Social Security No.: ________________

Name:______________________ Home Phone: ____________________

Address:____________________ Work Phone:_____________________

City____________ State______ Place of Employement: _______________

Zip Code___________Age________

Spouse/Child Name Age School/Employer Birth Date

___________________________________________________________________________

Are you a single parent household? Yes / No

Type of Financial Assistance: _____Membership

_____Program

_____Category

_____Childcare

Have you ever applied for scholarship assistance before at the YMCA?_________

Present Income Level:____________________

What is the dollar amount you have the ability to pay each month? $________

What benfits do you see in having this scholarship to join the YMCA as a member or participant?

___________________________________________________________________

Why are you applying for scholarship assistance?

___________________________________________________________________

What volunteer services can you provide to the YMCA?

___________________________________________________________________

Please itemize your monthly income and expenses:

Salary/Tips $___________ Rent/Mortgage $_________________

Uemployment Comp. $___________ Utilities $_________________

Social Security Comp. $__________ Food $_________________

Child Support $__________ Clothing $_________________

No. of Dependents $__________ Phone $_________________

Food Stamps $__________ Car Insurance $_________________

401K Retirement Fund $__________ Medical $_________________

Alimony $__________ Child Support $_________________

Other $__________ Other $_________________

Total Income $__________ Total Expense $_________________