EXPERIENCE SCHOLARSHIP APPLICATION

Our Experience Scholarship Program is funded by the generosity of the community and takes every measure possible to forecast funding accurately, ensure that it’s allocated responsibly and that it remains available all year-round. While the Y strives to provide the most thorough consideration of all financial hardship in every application, rates provided are the very best possible within the program’s guidelines. We realize the reduced rate still may not work within everyone’s budgets, or that those previously receiving assistance will see an increase in their monthly rate, however the Y will never offer a rate that is not the best possible award for each application.

START YOUR APPLICATION

Have you or anyone else within your household applied for an Experience Scholarship within the last 12 months?

Yes

I understand that if approved, my membership must be started within 30 days. Once an award expires, I am ineligible for further review for 12 months from the date of my original application.

I understand that if I, or anyone else within my household, has already applied for an Experience Scholarship within the last 12 months, my application will not be accepted by the Experience Scholarship Department.

I understand that if I falsify any information requested, I will not be eligible for assistance now and/or in the future.

I understand that once the verification process has begun, requesting to change information pertaining to my household members, income, or other matters which might affect eligibility, may result in immediate denial.

I understand Experience Scholarship assistance and overall rates have changed. If determined eligible, the rate awarded is non-negotiable.

First-time applications and current members renewing an Experience Scholarship are of highest priority.

An Experience Scholarship must be redeemed by starting the membership within 30 days of approval and is valid for one year from the date the membership is started.

We are unable to accept an application at this time if:

you, or someone else within the same residence, has submitted an application within the last 12 months and you are not a current member renewing an active scholarship membership
you were approved within the last (12) months and started your membership but has since been cancelled for any reason.

If you need further assistance, email Membership@RochesterYMCA.org

First

Last

Please use this same email address for any future correspondence regarding your application.

Phone

Date of Birth

Address

Street Address

City

State/Province/Region

ZIP/Postal Code

Ethnicity

If Other, please specify

A Passport Membership allows you to access any YMCA of Greater Rochester facility. Your chosen location is where you will be able to set up your membership.

If approved, indicate the type of Experience Scholarship that best fits your needs (If you are requesting a scholarship for camp only, please reach out to that camp site directly):

Membership Only

Before & After School Program Only

Membership + Before & After School

Membership + Camp

Membership + Before & After School + Camp

Before & After School +Camp

Indicate if you currently do, or intend to, enroll in any of the following programs available to members only:

Programs: Youth Sports, Swim Lessons, etc

Partial Day Preschool

Swim Team

School District

If other, please enter your school district and school name. Please note: For information on Rochester City School District Before & After School Program Assistance, please reach out to our Carlson Child Care Center at 585-263-4283.

Bloomfield Before & After School Program Sites

Brighton Before & After School Program Sites

Canandaigua Before & After School Program Sites

Churchville-Chili Before & After School Program Sites

East Irondequoit Before & After School Program Sites

East Rochester Before & After School Program Sites

Fairport Before & After School Program Sites

Gananda Before & After School Program Sites

Gates Chili Before & After School Program Sites

Greece Before & After School Program Sites

Hilton Before & After School Program Sites

Livonia Before & After School Program Sites

Penfield Before & After School Program Sites

Pittsford Before & After School Program Sites

Red Jacket Before & After School Program Sites

Victor Before & After School Program Sites

Wayne Before & After School Program Sites

Webster Before & After School Program Sites

West Irondequoit Before & After School Program Sites

Membership Options

Location(Please select your home branch where you will initially set up your membership. Once a Passport member, access to all locations is included.)

Locations ROC City

Will you be included on this membership?

Yes

Provide the name and date of birth (MM/DD/YYYY) for each individual residing at your residence, even if they will not be included on the membership.

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on membership?

Yes

First

Last

Date of Birth

Include on Membership

Yes

If you’re unable to pay the regular rate due to recent, extenuating circumstances beyond your control that significantly impact your financial situation, please provide details. Please note: You must be able to provide documentation to support your claim in addition to your proof of income. Situations not considered: mortgage or car payments, personal debts, standard living expenses, discretionary expenses, saving for a large expense such as a home or wedding, etc.

How do you currently pay for housing?

I pay rent.

I have a mortgage payment.

I no longer have a mortgage payment. My mortgage has been paid off.

None of the above.

On average, how much do you spend monthly in total on housing expenses, including mortgage or rent payments, insurance, utilities, internet, etc.?

On average, how much do you spend monthly in total on transportation expenses, including car payments, insurance, gas, regular maintenance, RTS passes, etc.?

I acknowledge that the YMCA of Greater Rochester uses publicly available information such as census datasets provided by HUD, and Federal Poverty Guidelines as a reference in determining eligibility. Eligible applicants are approved based on complete and accurate household information, including all household members and their income, regardless of membership status. Scholarships are approved on a sliding scale based on financial need according to State and County Cost of Living Guidelines and Federal Poverty Guidelines.

I acknowledge that applicants seeking an Experience Scholarship with income and/or sufficient resources that would otherwise qualify them for an Experience Scholarship would be expected to use those resources and/or pursue any other forms of available assistance first to contribute to their membership cost as determined by the Y in its discretion.

In addition to the information provided in the application, the YMCA of Greater Rochester uses publicly available information provided by, but not limited to, a third-party subscription-based data service to determine eligibility. The Y reserves the right to consider an applicant’s income as well as assets in determining eligibility

I acknowledge that applicants who exceed the income threshold may be considered for approval at the sole discretion of the YMCA of Greater Rochester if they face extraordinary medical costs or have other unique or extenuating, documentable circumstances. Eligibility determination in complex cases will be determined after thorough consideration and all pertinent information is verified by the YMCA of Greater Rochester.

Does anyone in your household receive assistance through SNAP or HEAP?

SNAP

HEAP

Both

None

I understand that:

I may be required to provide a copy of my SNAP and/or HEAP "Notice of Decision" statement.
My application will not be processed if only the front pages are submitted. The application will remain pending until both front and back pages are received.
Anyone listed on my application that is not included in my SNAP and/or HEAP letters is subject to ineligibility.
I must include all individuals living in my household and provide accurate income information for each, whether or not they will be included in any membership and/or service I am applying for.
If I do not provide adequate supporting documentation for all household members as stated above, that my application will not be processed.

The application will not be processed if only the front pages are submitted. The application will remain pending until both front and back pages are received.

I understand that anyone listed on my application that is not included in my SNAP and/or HEAP letters is subject to ineligibility

I agree, if necessary, to send additional information and documentation to support any of the following information provided.

I acknowledge that I must include all adults living in my household and provide accurate income information for each, whether or not they will be included on the membership I am applying for.

I understand that if I have not provided adequate supporting documentation to show proof of income for each member in household, whether or not they will be on the membership, that my application will not be processed.

Household Income Recipient 1 First and Last Name

Please Specify Other Financial Support for Income Recipient 1

Household Income Recipient 2 First and Last Name

Please Specify Other Financial Support for Income Recipient 2

Household Income Recipient 3 First and Last Name

Please Specify Other Financial Support for Income Recipient 3

Household Income Recipient 4 First and Last Name

Please Specify Other Financial Support for Income Recipient 4

Household Income Recipient 5 First and Last Name

Please Specify Other Financial Support for Income Recipient 5

Will your membership and/or program be paid for, either partially or in full, by an outside organization (e.g. OPWDD/Self-Direction, County, Agency, Care Manager, etc)?

Yes

Please indicate the household member(s) with the approved agency funding.

Please provide the contact information (email address if known) for your agency representative.

I certify that the information provided is true and complete to the best of my knowledge. I understand that census data, public records, state, and county guidelines, along with the information I have provided will be used to determine eligibility.

I have reviewed that all information provided, such as household members, income, address, living arrangements, or other matters which might affect my eligibility, has been fully disclosed and accurate. Changes to a pending or approved application are prohibited and may result in immediate denial of scholarship privileges.

I understand that if my application is approved, I have 30 days to begin my membership. Once the offer has expired, my eligibility cannot be determined again for one year from the original date of approval.