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.

The following documents are required for income verification:
Recent check stubs (2) or letter from your employer verifying salary
Current year's Income Tax Return (first page only)
Any court ordered support such as child support, if applicable.
Any household income such as disability or state assistance, if applicable.

Submit your income verification documents within 30 days to guarantee your reduced rate for the school year. Income can be verified in-person by your school site director, at the local YMCA, or by email to the billing department. If income is not verified within 30 days, the weekly fee will revert to the regular rates. Fax number (901) 766-7687

Email address *
Parent/Guardian Name
Your answer
Parent/Guardian Date of Birth
Your answer
Address:
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
School or Summer Camp Attending
Your answer
Program Needs
Special circumstances related to your request
Your answer
Annual Household Income (before taxes)
If income is under $30,000 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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