YMCA of Silicon Valley - Financial Assistance

COMMITTED TO OUR NEIGHBORS
YMCA of Silicon Valley is here to serve all communities. As part of this commitment, we allocate resources to provide financial assistance to those that need help. Through our Annual Campaign, the Y raises and distributes funds on a first-come-first-serve basis to youth, adults, and families based on individual needs and circumstances.

Page 1 of 2 - Personal Information

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PRIMARY ADULT
Name Name First Last
Phone Phone - ### - ### ####
Email
Date of Birth Date of Birth / MM / DD YYYY
I have an active YMCA Membership.

I have an active YMCA Membership. Yes - My Membership is Active Yes - My Membership is On Hold No - I do not have an Membership
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do you receive income?

Do you receive income? Yes No
Are you employed?

Are you employed? Yes - Part Time Yes - Full Time No Retired
Are you enrolled in school?

Are you enrolled in school? Yes - Part Time Yes - Full Time No
Do you own or rent a home?

Do you own or rent a home? Own Rent Unhoused
SECONDARY ADULT
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Are you employed?

Are you employed? Yes - Part Time Yes - Full Time No Retired
Are you enrolled in school?

Are you enrolled in school? Yes - Part Time Yes - Full Time No
Do you own or rent a home?

Do you own or rent a home? Own Rent Unhoused
HOUSEHOLD MEMBERS
Are their additional Household members that you would like to include as part of your Financial Assistance Application?

Note: Members must be listed on the application in to order to receive Financial Assistance.

Are their additional Household members that you would like to include as part of your Financial Assistance Application?

Note: Members must be listed on the application in to order to receive Financial Assistance. Yes No
Member #1
Name Member #1
Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Name of School(s) currently attending:
Member #2
Name Member #2
Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Name of School(s) currently attending:
Member #3
Name Member #3
Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Name of School(s) currently attending:
Member #4
Name Member #4
Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Name of School(s) currently attending:

YMCA of Silicon Valley - Financial Assistance

YMCA of Silicon Valley - Financial Assistance

Page 1 of 2 - Personal Information

PRIMARY ADULT

SECONDARY ADULT

HOUSEHOLD MEMBERS