Child Care & Camp Financial Assistance Application

(Not valid for membership and/or other Y programs.)

The Child Care and Camp branch of the Greater Wichita YMCA is committed to making our programs available to all children. We strive to support families and ensure everyone has the opportunity to reach their potential. Each year, the YMCA raises funds through our Annual Campaign to provide financial assistance. Additionally, the Child Care and Camp branch works diligently to secure funds through grants and other community partnerships to ensure no child is turned away. While the basis for assistance is family income we do take into consideration other extenuating circumstances. The YMCA believes a strong sense of ownership and pride is developed if the recipient has contributed to the cost of their YMCA involvement; therefore applicants will be asked to pay some portion of the fee. Child Care financial assistance awards are valid for up to one year, at which time applicants must re-apply.

1. PARTICIPANT INFORMATION

Participant Name

Date of Birth

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Parent/Guardian #1 Full Name

Parent/Guardian #1 Phone

Parent/Guardian #2 Full Name

Parent/Guardian #2 Phone

Parent/Guardian Email Address

Note: You will be notified by email regarding your financial assistance award

Who has custody of the participant? Check one.

Joint

Mom

Dad

Guardian

Foster Care

2. I AM APPLYING FOR

Early Childhood Program: 2 Weeks to Pre-K

Early Learning Center (Full day, full year child care)

Child Development Center (School year child care)

School Age Programs: KG - 12 Years (Camp Hyde is up to 16yrs)

Before and/or Afterschool Care

YMCA Summer Day Camp

Indicate specific location, if you know:

Amount I can pay weekly:

Parent/Guardian #1

At Home

Working

Attending School

Parent/Guardian #2

At Home

Working

Attending School

3. To Apply for Assistance, Provide the Following Documents for Each Adult in the Household

Total annual household income:

Select the forms that you are able to provide:

I filed federal taxes last year and have the 1040 federal tax form for ALL ADULTS in the household

Upload 1040 federal tax form(s) here if applicable:

One file only.
64 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Upload SSI/Disability award letter if applicable:

My household income has changed since I filed taxes last year

Documents showing most recent 30 days of income (including pay stubs or documentation of government assistance):

Total annual household gross income:

Do you receive child care assistance from DCF, or any other 3rd party agency?

Yes (If yes, please provide documentation of the assistance provided)

Upload documentation of assistance provided:

4. ALL PERSONS LIVING IN THIS HOUSEHOLD

Parent/Guardian/Adult:

Enter all children in household:

To add a child or children, click the plus icon to the right, or click the "Add" button below.

Re-order	Child:	DOB:	Weight	Operations
	Child:	DOB:	Item weight

more items

5. STATEMENT OF NEED

Please use the space below to include any information or extenuating circumstances that were not included on this application.

6. PLEASE READ AND INITIAL THE FOLLOWING STATEMENTS

REMINDER: THIS APPLICATION MUST BE COMPLETED FOR EACH PARTICIPANT AND PROGRAM YOU ARE APPLYING FOR.

I certify that the above information is true and complete to the best of my knowledge, and that I do not have additional income not represented in this application. I agree, if necessary, to send additional information and documentation to support the above statements. I understand that scholarship assistance is based on need. I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future. The YMCA may ask for clarification of documentation or circumstances. Submitting this application does not guarantee placement in a program. Available funds are due to the generous donations of our staff and community as well as community partnerships and grants awarded to the Greater Wichita YMCA Child Care and Camp branch. Continuation of financial assistance is subject to available funds.

Signature of person completing this form:

Sign above

Completed application takes up to 10 business days to process.

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