EXPERIENCE SCHOLARSHIP APPLICATION

I understand that if I’ve already applied for an Experience Scholarship and/or been awarded, I may not be eligible to apply at this time based on the date of my original application or award.

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

I have read and understand the information provided by the YMCA regarding the adjustments and new terms of this application process.

I understand Experience Scholarship assistance and overall rates have changed. Members 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 within the program’s guidelines. If determined eligible, the rate awarded is non-negotiable.
Examples showing a few of our most common Passport Membership types at their lowest possible rates:
Adult Membership: $27.65/mo
Individual Parent: $33.30/mo
Family: $37.80/mo

If you are submitting a duplicate application, your current place in the queue will be pushed back to the furthest date for review based on only the most recent submission. If you have already been awarded within the last year, please contact our Experience Team at Membership@RochesterYMCA.org who will determine if reapplying is necessary.

First and Last Name

Email

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

Phone

Date of Birth

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.

Membership Options

Location

Locations ROC City

List all household members, including yourself, by names and dates of birth, even if they will not be included on your membership (ie: John Smith 1/1/50, etc).

Ex: John Smith, 01/01/1970

Select Membership Type

Of the household members provided above, including yourself if applicable, list each member to be included on this membership. Please review the membership type selected above. The household members to include should accurately reflect the description of the membership type chosen above.

Member 1 First and Last Name

Member 2 First and Last Name

Member 3 First and Last Name

Dependent 1 First and Last Name

Dependent 2 First and Last Name

Dependent 3 First and Last Name

Dependent 4 First and Last Name

Dependent 5 First and Last

If you’re unable to pay the regular member 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.

Please share any measures taken that would demonstrate your efforts to improve your financial situation. For example, if an adult household member is unemployed, has a claim for Unemployment Benefits been filed, or have they been actively looking for employment?

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 the Federal Poverty Guidelines as a reference in determining eligibility. Eligible applicants are approved based on full and accurate household information and household size. If a determination is income-based and total household income is verified, Experience Scholarships are approved on a sliding-scale basis according to State and County Cost of Living Guidelines and Federal Poverty Guidelines.

I acknowledge that applicants seeking an Experience Scholarship are expected to seek and pursue any other forms of available assistance to obtain additional sources of income. The YMCA of Greater Rochester may use publicly available information to determine eligibility. The Y reserves the right to consider an applicant’s assets as well as income in determining eligibility. Applicants with income that would otherwise qualify them for an Experience Scholarship who have sufficient resources would be expected to use those resources to contribute to their membership cost as determined by the Y in its discretion.

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, have filed for bankruptcy, or have other unique or extenuating circumstances. Eligibility determination in complex cases will be determined after thorough consideration and all pertinent information is verified by the Experience Scholarship Coordinator.

I understand that I may be required to provide a copy of my SNAP and/or HEAP benefit letter(s).

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

If yes, please indicate the member with the approved agency funding, and the contact information (email address if known) for your agency representative.

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

I understand that all information provided is accurate and acknowledge that it will be verified by the Experience Scholarship Department.

EXPERIENCE SCHOLARSHIP APPLICATION

START YOUR APPLICATION

Ex: John Smith, 01/01/1970