MEMBERSHIP FOR ALL APPLICATION
Fond du Lac Family YMCA, 90 W. 2nd Street, Fond du Lac, WI
This application is for residents of Fond du Lac County, WI and the surrounding communities. Please contact your local YMCA for financial assistance options if you do not live in this area. FIND YOUR Y at https://www.ymca.org/find-your-y.
After your application is reviewed you will receive an email within 1-3 business days, indicating whether your application was approved or denied. Membership for All approvals require membership enrollment within 30 days of approval or re-application is required.
APPLICANT INFORMATION
Is this a new application, or are you reapplying because the financial assistance information we have on file for you is expiring?
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NEW APPLICATION
REAPPLYING FOR FINANCIAL ASSISTANCE
Applicant Name
*
First Name
Last Name
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Email
*
example@example.com
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
HOUSEHOLD INFORMATION
Provide full name and date of birth of all persons living in the household.
How many individuals reside in your household?
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Name of Applicant
*
First Name
Last Name
Applicant Date of Birth
*
-
Month
-
Day
Year
Date
2nd Parent/Guardian
First Name
Last Name
Date of Birth of 2nd Parent/Guardian
-
Month
-
Day
Year
Date
Dependent 1
First Name
Last Name
Dependent 1 Date of Birth
-
Month
-
Day
Year
Date
Dependent 2
First Name
Last Name
Dependent 2 Date of Birth
-
Month
-
Day
Year
Date
Dependent 3
First Name
Last Name
Dependent 3 Date of Birth
-
Month
-
Day
Year
Date
Dependent 4
First Name
Last Name
Dependent 4 Date of Birth
-
Month
-
Day
Year
Date
Dependent 5
First Name
Last Name
Dependent 5 Date of Birth
-
Month
-
Day
Year
Date
Dependent 6
First Name
Last Name
Dependent 6 Date of Birth
-
Month
-
Day
Year
Date
TYPE OF MEMBERSHIP APPLYING FOR
Please choose one.
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YOUTH (Ages 8-18)
YOUNG ADULT (Ages 19-30)
ADULT (Ages 31-64)
SENIOR (Ages 65+)
FAMILY/HOUSEHOLD (One adult or two adults and dependent children through the age of 25, all residing in the same household. Dependent senior adults or dependent adults with a disability, living in the household, may be included)
SENIOR FAMILY/HOUSEHOLD (Two adults residing in the same household. Primary member must be age 65+.)
MONTHLY HOUSEHOLD INCOME INFORMATION
Please list total MONTHLY income in household.
TOTAL ANNUAL HOUSEHOLD INCOME
*
$0 - $15,000
$15,001 - $25,000
$25,001 - $35,000
$35,001 - $45,000
$40,001 - $55,000
$55,001 - $65,000
$65,001 - $80,000
TO QUALIFY, PROVIDE COPIES OF THE FOLLOWING DOCUMENTS AS APPLICABLE:
UPLOAD FILES: 1040 Federal Tax Form(s) for all incomes in household:
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UPLOAD FILES: Documents showing most recent income; either 2 pay stubs per individual with income or documentation of government assistance:
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UPLOAD FILES: Additional forms of income (if applicable) Social Security, pension, unemployment, Child Support, Housing Assistance, Child Care support, etc.
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of
UPLOAD FILES: If you did not file taxes, letter from IRS stating you did not file.
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Choose a file
Cancel
of
Please tell us how receiving financial assistance through the Membership for All program will impact you/your family.
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THIS APPLICATION MUST BE RENEWED EVERY 12 MONTHS
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 above. I agree, if necessary to send additional information and documentation to support the above statements. I understand that sponsorship assistance is based on need. In the event that I or my children must cancel our participation, I will contact the Y immediately so sponsorship can be provided to others. I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future.
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