NERD YMCA of Natrona County
SCHOLARSHIP APPLICATION
Fill out the scholarship and membership applications completely. Once filled out, please return the forms
along with proof of income, to the YMCA at 1611 Casper Mountain Road, Casper, WY 82601, or drop it off
at the Welcome Center.
You will be notified within 5 business days of the amount you qualify for. Scholarships are awarded on a
6-month basis. You have the choice of paying the entire 6 months up front or opting for bank draft/auto
withdrawal with the monthly amount automatically deducted from your account. At the end of the 6month period, you will be able to reapply as necessary.
Date: _________________
Name: _____________________________________________________ DOB: ___________________
Address: ___________________________________ City/State: ________________ Zip: ___________
Phone: (H) _________________ (W) _______________ E-mail: ________________________________
Place of Employment: _____________________________________ Length of Employment: _________
Family Members:
1. _____________________ DOB _____________ 5. _____________________ DOB ______________
2. ____________________
DOB _____________ 6. _____________________ DOB ______________
3. ____________________
DOB _____________ 7. _____________________ DOB ______________
4. ____________________
DOB _____________ 8. _____________________ DOB ______________
Applying for assistance for: _______ Membership
_______ Program
Have you ever applied for scholarship assistance before at the YMCA? _____ If Yes, which YMCA, and
what for?
__________________________________________________________________________________
Did you provide a volunteer service? ___ Would you like to provide volunteer service for the YMCA? ___
Why are you applying for scholarship assistance?
____________________________________________________________________________________
What benefits do you see in having this scholarship to join the YMCA as a member or participant?
____________________________________________________________________________________
NERD YMCA of Natrona County
1611 Casper Mountain Road Casper WY 82601
P 307 234 9187 F 307 234 5656
www.casperfamilyymca.org
YMCA of Natrona County
SCHOLARSHIP APPLICATION
Page 2
Your present monthly household income: $ ______________
Proof of income must be provided, which could be any one of the following: Last year’s IRS Tax
Statement, benefit statement, SSI allocation statement, pay stub, etc. If you have no income, attach
a brief note describing how you provide food, clothing, and housing for your household and
when you expect to receive income.
Please itemize your monthly income:
INCOME
MEDICAL HARDSHIP
Wages/salaries/tips: $
Approximate medical bills:
Unemployment:
$
Social Security:
$
Child Support:
$
$
Aid to Dependent Children: $
Food Stamps/SNAP:
$
401(k)/Retirement:
$
Alimony:
$
Other:
$
___________________________________________________________________________
FOR OFFICE USE ONLY
Approved monthly scholarship amount: __________
Membership Type: _________________________
Payment Plan:
________ Semi-Annual
________ Monthly Bank Draft
YMCA Manager Signature: ___________________________________________________
Manager Name: _____________________________________ Date: _________________
Thank you to the United Way of Natrona County and donors of our Strong Kids Campaign for making
these scholarships possible for the YMCA.
NERD YMCA of Natrona County
1611 Casper Mountain Road
(307) 234-9187
Casper, WY 82601