TO OBTAIN
A SCHOLARSHIP
 Complete this application form and return it
with proof of income to our office. We will
review the information and compare it to
established scholarship guidelines.
 All information will be kept confidential.
Scholarship Check List
All documentation requested below is required to
process this scholarship application.
• Scholarship Application completed and signed
Copy of a valid driver’s license or picture ID
•
• Proof of income (two of the following)
Most recent tax return or W2
Last two pay stubs for all working adults
in the household
Unemployment Benefits Statement
• YWCA change of provider form and
statement copy
Are you (and your family) able to volunteer the Y?
Yes
SCHOLARSHIPS
•
The Y seeks to give aid for anyone who desires to
participate, regardless of their ability to pay
program fees. Those not able to pay the full fee
may receive assistance based on their ability
to pay.
•
Scholarships are available for most programs,
however the amount is based on available
funding and limitation may apply.
•
It is unusual that 100% of the fee is provided.
While the Y is a non-profit agency, we depend
on participant fees and community support to
help maintain our services. Therefore, we expect
participants to pay fees based on their financial
ability.
Events
Clerical Education
Programs
Other____________________________________
__________________
OUR CAUSE...
To strengthen the community through a focus
on Youth Development, Healthy Living, and
Social Responsibility.
Practical assistance for...
• Youth and family on limited income
•
No
If yes, what are your volunteer interests?
TRI-TOWN YMCA
SCHOLARSHIP PROGRAM
•
Our Scholarship Program is funded through
donations to the Y.
• Families who are temporarily unemployed,
overwhelmed by medical bills or are
experiencing other temporary financial difficulties.
Scholarships are provided for a specific time
period. When that time is up, if help is still
needed, you may reapply. There are two
methods of payment. You may pay in full, or
via monthly Electronic Funds Transfer from
checking or credit card account.
TRI-TOWN
YMCA
1464 S. MAIN ENTRANCE7
LOMBARD, IL 60148
PHONE: 630-629-9622
FAX: 630-629-4636
WWW.TRITOWNYMCA.O
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EMAIL:[email protected]
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TRI-TOWN YMCA SCHOLARSHIP APPLICATION
All Questions must be answered completely (please print clearly)
Name of Participant
Type of Program You Are Requesting
Camp
Participant Date of Birth
Before & Afterschool:
Applicant Name
Ardmore
Address
Madison
City
Manor Hill/Hammer Schmitt
State
Pleasant Lane/Parkview
Zip
Schafer/North
Email
Westmore
Daytime#
Home#
Have you Previously Applied for a Scholarship?
Parent-Child Program
Yes
No
Water Fitness
Household Members (includes adult couples and legal dependents)
Relationship
Are you currently a Y program participant?
No
Yes
Birthdate
Age
Ethnicity
If yes, where
Please give a short explanation of WHY you need a Scholarship. Attach a separate sheet of paper if needed.
Income Information
Applicant’s Employer
Full Time
Part Time
Hours Per Week
Annual Income
Part Time
Hours Per Week
Annual Income
Spouse’s Employer
Full Time
If you receive or have applied for any of the following income sources, please fill in the annual amount:
Child Support $
Alimony $
Social Security/Social Security Disability $
Food Stamps $
Other Income from you and from household members $
Annual Income From All Sources $
I understand that this Scholarship is for current session only and I must reapply for future program sessions scholarships.
Applicant’s Signature
Date