Financial Assistance Application

As a charitable organization, The Family YMCA is committed to assisting individuals who might not otherwise be able to afford our programs. Financial assistance is based upon available resources.  Funds are allocated out of the donations we receive from local businesses, organizations, and individuals that are received during our Annual Campaign.

Financial assistance is awarded on a sliding scale and is based on a review of the applicant's household income and extenuating circumstances. Life can be challenging and personal situations can be complex in ways that are not represented by numbers on a page.
 
All information is kept confidential. This application must be renewed every 6 months.
 
Our financial assistance is for individuals living in Northern New Mexico and utilizing our programs in Los Alamos, Espanola, and Taos. It is only applicable to membership & programs run by The Family YMCA. 

Note: Participation in our Los Alamos After-School programs are limited to children who are enrolled in LAPS.
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Personal Contact and Household Info
Applicants Name: *
Home address - include city, state, and zip code:
(Please hit return after each line to keep things organized.) *
Preferred contact phone number: *
Alternate contact phone number:
Email address:
(All financial assistance notifications are made via e-mail. Please be sure to give us an email you check regularly.)  *
Employer or school you attend (if any):
(enter none if you are not employed or in school) *
Marital Status: *
How many adults (including yourself) live in your household? *
How many children (18 and under living at home) are in your household? *
Household Member Information
Please provide the name, age, and relationship of all of the members of your household (spouse/partner, and dependents) in the spaces below.
Household Member #1
Household Member #2
Household Member #3
Household Member #4
Household Member #5
If you have more than 5 members in your household, please provide their names, ages, and relationship to you in the space below.
(Please hit return after each line to keep things organized.)
I am requesting financial assistance for:
(check all that apply) *
Required
Requested Financial Information
As part of the financial assistance application process we will need to see some documentation of income. Copies of the requested documentation will need to be emailed to our financial assistance staff. You will be contacted about this after your application is reviewed.

Gross household income is evaluated based on:
  • 4 recent consecutive pay stubs for all applicable household members
  • State/Federal Aid statements for applicable household members
  • Any other source of income not listed above (investment income, trust, etc)
Please include your estimated gross monthly household income in the questions below. We will use the information provide to give you an estimate of what level of financial assistance you qualify for. This will be verified when you bring in the requested documents.
Your total gross monthly household income  - this includes all earned income, state & federal government aid (Foster Care, Disability, Unemployment, SSI, etc), child support/alimony  *

Please share any special/extenuating circumstances, outside of income, that we should consider when evaluating your application.

 *
I certify that the above information is true and complete. I agree to inform The Family YMCA of any changes in my financial status that might impact my level of financial assistance. I understand that my award is based on funds available and my award can change at any time. My application for assistance will not be complete until I have provided my most recent documentations of income.

I agree to provide a written testimony of how financial assistance has helped me/my family within 60 days. 

By typing my full name in the field below I am agreeing with the statement above.
 *
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