a Valley of the Sun OPEN DOORS PROGRAM Here is some Important information that vou should know about YMCA’s OPEN DOORS program. Please allow 3 weeks to process your application. Individuals will be notified by mail whether or not they qualify for the VMICA OPEN DOORS program. In order for any OPEN DOORS application to be processed, Individuals must provide all requested information along with proof of all household income. ‘The YMCA OPEN DOORS program will award a maximum of 30% off membership, program, and childcare fees, Some specialty services are excluded from the OPEN DOORS program. AILYMICA Meinbierships must be paid through checking, savings, or credit card bank draft or paid in fullfor 6 months, ‘The Membership lotiing Fee will be waived upon acceptance into the OPEN DOORS program. Allaccepted OPEN DOORS applications for YMCA expire 6 months after approval. You must include’current financial information each time you re-apply. Program, rhembership, and childcare fee’s are subject to Inerease when you re-apply for the ‘OPEN DOORS program. AILYMCA members receive the same membership benefits, and childcare, regardless of whether or not they are receiving assistance, ‘TO PROCESS YOUR APPLICATION, WE WILL NEED COPIES OF ANY ITEMS BELOW THAT APPLY TO YOUR FINANCIAL CIRCUMSTANCES: Last year’s 1040's / W2's Last year’s tax return Last two recent pay stubs Soclal Security or Disability Child support or alimony Food Stamps Aid to dependant children Welfare Retirement or Pension DES worksheet Documentation of any and all Income for your household aod shreapioneOPEN DOORS PROGRAM \PPLICATIONS WILL BE PROCESSED ONLY AFTER ALL INFORMATION IS SUBMITTED AND THE ‘APPLICATION IS FILLED OUT COMPLETELY. PERSONAL INFORMATION: batieg {_) ita EA Head of iouschod Home Telephone ‘cel uinber Seat Aderess cy state 2p LIST FULL NAMES AND AGES OF ALL PERSONS IN THE HOUSEHOLD: Your household Includes dependants you clalm on your federal income tax return. ea au /aF Fist lame Test name Date afith ead. am sar Fist Name Tastaine Date oF ith Lt aMsar Fist Name Test name Date ofeith a aa am sor FistName Tast name Date of ith a om sar FistName Tat name DateoFeih ig Qmsar FistName Tast name Date oF : fat om/or FirstName Tastname Date of Ith tt am /oF Fist Name ‘st name Date of with EMPLOYMENT INFORMATION: Company: eee et) Postion Office Telephone ‘Street Adress : — eR State Zp Length of GuiTime Gross wonthiy income: Employment: Yeats) Month(s) CLPart Time (eoresees/deducion) aoe ‘SPOUSE / PARTNER EMPLOYMENT INFORMATION: Company: ie t) Poston Offce Telephone Breet Address iy State Te Length of DullTime Gross Monthy Incomes Employment: Year(s) ___ Month(s) QPart Time —_aetoretmes/aeectors} psresa/AnecanattcineGpn dee and eneValley of the Sun OPEN DOORS PROGRAM Expenses: Cliortgage - Cent ‘Auto Loan utilities Phone puteeinyoorrss} Child Support Alimony Medical stincueag trance) childcare other other Other Total Monthly Expenses Gross Monthy Income $ Spouse Monthly income $ Cchitd Support $ Welfare 8 Food Stamps $ Disabty $ $ 3 $ $ 3 Soclal Security Allmony other other Total Monthly income Do you share expenses with anyone else in your household? Yes No Are you a full time student? Yes No Ifyes, where? Number of adults in household ‘Number of children in household ‘TYPE OF MEMBERSHIP YOU ARE APPLYING FOR: (check one] Family {2 adults + children) Q Famly | (1 adult + children) Q Adit Student (ages 14-18) a Young Adult (up to ages 28) J Youth a Senior Senior TYPE OF PROGRAM YOU ARE APPLYING FOR: (Check all that apply) Adult Programs Youth Sports Childcare / Preschool ‘Aquatics: Childcare / Schoo! Age Teen Programs Childcare / Summér Day Camp Other (speciy OTHER INFORMATION THAT MAY HAVE BEARING ON THIS APPLICATION: * Lunderstand that | will be required to pay a portion of the program or membership fee's that | am. applying for. understand that | must re-apply for my OPEN DOORS scholarship every six months, in order to keep ‘my OPEN DOORS scholarship and membership active. * understand that its my responsibility to re-apply for my OPEN DOORS scholarship before the, explration date, which was givan to me on my approval letter. Applicant's Signature vse selsiomnaranitatrai nso beard Ae