CONFIDENTIAL SCHOLARSHIP APPLICATION

YMCA of Northern Michigan • 622 Howard Street • Petoskey MI 49770

Request for: Membership Day Camp

Youth Sports Y-Center
Martial Arts Other
PERSONAL Child's name___________________________________________________________
Parents/Guardian's name_________________________________________________
Address______________________________________________________________
City____________________________________________
State______________ Zip_______________________
Phone_______________________ Work/Cell_______________________________
School_______________________ Birth Date__________ Grade
Email_________________________________________________________________
Family at Home: [ ]Mother [ ]Father [ ]Sisters #___ [ ]Brothers #____
Do you qualify for free of reduced lunch? (circle) Yes / No
Do you have a current YMCA membership? (circle) Yes / No

EMPLOYMENT Are you currently employed? (circle) Yes / No

YOU SPOUSE
Employer Employer
Address Address
Occupation Occupation
Length of time with employer_____ Length of time with employer _____

INCOME Proof of income may be requested.

Monthly Gross $___________ Spouse's Monthly Gross $_________
Other Income (child or spousal support, etc.) $__________________________
If you receive State or Federal aid, food stamps, medial aid, etc., please list:

EXPENSES List extraordinary expenses:

GENERAL Please share your reason for requesting financial assistance:

State the dollar amount you could contribute toward the program fee $______________

Applicant's Signature Date

Y services and programs are designed for the entire community.
The YMCA of Northern Michigan scholarship program helps assure an opportunity for all to
participate in activities at the Y based on their ability to pay.
Office Use Only
Date Application Submitted Type of Membership/Program awarded
Cost of Membership/Program
Amount Granted Session _____
Amount Owed