Flexible Pricing Membership Registration

First Name *

Last Name *

If you are under 18 please enter your parent’s or legal guardian’s name

Street Address *

Address Line 2

City *

State *

Email address *

Zip Code *

Phone Number *

Preferred contact method

Please fill out the date of birth for all people living in the household

(1-2 adults and their dependent children under the age of 24 living in the same household).

Adult: Full Name *

Age * +

Adult: Full Name

Age +

Dependent: Full Name

Age +

Dependent: Full Name

Age +

Dependent: Full Name

Age +

Dependent: Full Name

Age +

Check the membership category that you would like to have. *

Adult (Ages 24-59)	Family
Senior (60+)	Senior Couple (Both Age 60+)

If you are seeking a unique rate for a program such as summer camp or swimming lessons, please list the name of the program below.

Total annual income *

Please provide a copy of a recent pay check stub, 1040 tax form (latest copy) and any other income supporting documents reflecting income or lack thereof.

Attach any supporting documents
(1040 IRS Tax Form, Recent Paystub, Proof of Government Assistance, etc.) *

If you'd like to tell us more; Use this space to include any additional information, extenuating circumstances or examples (major medical expenses not covered by insurance, divorce, job loss, change in income, etc.) that were not included in this application.

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 flexible pricing is based on need. In the event that I or my children must cancel our participation, I will contact the YMCA immediately so that this benefit may 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.

*

clear

Applications are reviewed on the 1st and 15th of each month. You will then receive a determination letter by mail or email. Please do not contact the branch to check on your application as we will get back to you as soon as possible.

Thank You!