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Greater Pittston YMCA 10 North Main Street Pittston, PA 18640 Phone: 570-655-2255 Fax: 570-655-5110 |
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Guidelines for Application Effective 12/19/2003 The following guidelines have been developed to help make the process of awarding financial assistance easier for you. Please review the procedures and contact the Executive Director with any questions. 1. Applications for financial assistance should be forwarded to the Executive Director no later than the 15th of each month. 2. Applications MUST contain the financial documentation requested in order for review. Failure to provide the appropriate financial information will result in notification that the application is incomplete. Once the required information is furnished, the application will be reviewed at the next months period. 3. Applications for Financial Assistance will be reviewed monthly on the 20th of each month. 4. Awards for Financial Assistance will be mailed directly to the household by the 25th of each month. 5. There will be program specific time periods for review of special programs such as, Day Camp, Preschool and Before and After School Child Care. Please ask at the membership desk for more information on these programs. 6. Financial Assistance awards are based on household income, the number of individuals in the household and a statement of need. 7. Although the Greater Pittston YMCA strives to never turn anyone away for inability to pay, there are a limited number of funds available. Awards are granted on a first-come, first-served basis. 8. Please contact the Executive Director with any questions you may have. The Financial Assistance program is made possible through the Greater Pittston YMCA Strong Kids Campaign and the Wyoming Valley United Way allocation. |
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APPLICATION FOR SCHOLARSHIP ASSISTANCE Please fill out the following information and attach the necessary documents (photocopies only) and return to the Executive Director of the Greater Pittston YMCA. Please print all information. Date of Application____________________ Social Security #______________________ Name_________________________________ Home Phone#_______________________ Address_______________________________ Work Phone#________________________ City_______________________________________ State__________ Zip____________ Place of Employment_______________________________________________________ Household member information (include all adults who contribute to your monthly income and all children who may benefit from a Financial Assistance award) Name Age School/Employer Birth Date _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Are you a single parent household? ____Yes ____No Application for financial assistance for ____ Membership ____ Program (specify)___________________ ____ Child Care ____ Other _____________________________ Have you ever applied for scholarship assistance before? ____Yes ____No If yes, at which YMCA?__________________________________ Annual Household Income ____$0-$11,000 ____$11,001-$14,000 ____$14,001-$17,000 ____$17,001-$19,000 ____$19,001-$22,000 ____$22,001-$25,000 ____$25,001+ |
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Financial Assistance Application (con’t) What is the dollar amount you are willing to pay or have the ability to pay each month? Membership $_______________________ per month Program $_______________________ per month Child Care $_______________________ per month What benefits do you see in having this scholarship to join the YMCA as a member or a participant?_____________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Why are you applying for scholarship assistance?________________________________ _________________________________________________________________________ _________________________________________________________________________ What volunteer services can you provide to the YMCA?___________________________ _________________________________________________________________________ Please itemize your monthly income and expense items INCOME EXPENSE Wages, salary & Tips $___________________ Rent/Mortgage $_______________________ Unemployment Income $___________________ Utilities $_______________________ Social Security Income $___________________ Food $_______________________ Child Support $___________________ Clothing $_______________________ Aid to Dependant Children $________________ Phone/Cell $_______________________ Food Stamps $___________________ Car Payment $_______________________ 401K Retirement Fund $___________________ Car Insurance $_______________________ Alimony $___________________ Alimony $_______________________ Other $___________________ Child Support $_______________________ Total Monthly Income $___________________ Medical $_______________________ Other $_______________________ Total Monthly Expense $_________________ You must attach the current years or last years Internal Revenue Service Tax Statement and/or you SSI allocation statement to verify your annual earnings. |