Childcare Income Based Rates/Fee Assistance Application
Please complete and submit the form to the billing department for income based rates or additional fee assistance.

YMCA Child Care Services reserves the right to require household income verification including a 1040 tax form and a copy of the two most recent paychecks.
Email address *
Please list ALL Adults in household *First and Last Name *
Parent / Guardian Date Of Birth *
Address/City/State/Zip *
Phone Number *
Email Address: *
1st Child's Full Name *
1st Child's Date of Birth *
2nd Child's Full Name
2nd Child's Date of Birth
3rd Child's Full Name
3rd Child's Date of Birth
List name of school, camp, or preschool your child will be attending: *
Program Needs *
Special circumstances *
If unemployed, please explain why you need childcare
Please list total gross annual household income *
Please select the proper household income classification so we may best serve you *
Child Support *
Have you received fee assistance in the past? *
If yes, please explain.
Information provided above is true and correct. *
Signature *
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