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 may require household income verification including a 1040 tax form and a copy of the two most recent paychecks.

Email address *
Parent/Guardian First and Last Name *
Your answer
Parent/Guardian Date of Birth *
Your answer
Address/City/State/Zip *
Your answer
Phone Number *
Your answer
Email Address: *
Your answer
1st Child's Name
Your answer
1st Child's Date of Birth
Your answer
2nd Child's Name
Your answer
2nd Child's Date of Birth
Your answer
3rd Child's Name
Your answer
3rd Child's Date of Birth
Your answer
List name of school or camp your child will be attending: *
Your answer
Program Needs *
Special circumstances such as currently unemployed, recently moved, custody issues, foster children, etc.......
Your answer
Annual Household Income (before taxes) *
If income is under $20,000 please list amount below. *
Your answer
Child Support
Have you received fee assistance in the past?
If yes, please explain.
Your answer
Information provided above is true and correct. *
Signature *
Your answer
A copy of your responses will be emailed to the address you provided.
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