Open Doors Scholarship Application We are a supportive community inspiring all people to live healthier lifestyles
Apply for an Open Doors Scholarship in five easy steps! 1. Applicant Information Name First Middle Last Date of Birth Gender - Select -MaleFemale Email Address Email Address Confirm Email Address Mailing Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Home Phone Cell Phone If an applicant is under 18, Parent's or legal guardian's name YMCA Location - Select -Camarillo Family YMCALompoc Family YMCAMontecito Family YMCASan Luis Obispo County YMCASanta Barbara Family YMCAStuart C. Gildred Family YMCAVentura Family YMCAYouth and Family Services YMCA, St. George Youth Center Emergency Contact Information Emergency Contact Name First Last Relationship Phone 2. All Additional Persons Living in this Household Place a check mark for each family member applying for assistance Yes Name DOB Gender Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female 3. I Am Applying For Membership Teen Adult Family Senior Two Person Program Youth Activities Day Camp Sleepaway Camp Childcare(not available in all locations) Preschool(not available in all locations) Other Please specify program For Child Care and Camp Applicants Only What other child care options are available to you? Parent/Guardian #1 At Home Working In School Parent/Guardian #2 At Home Working In School 4. Please Provide the Following Documents Option 1: Fast Track Qualifying Document My household is enrolled in a federal, state or local government assistance program for food, housing or childcare such as CalFresh, SNAP, WIC, Medi-Cal, TANF, CSFP, HUD Voucher, Extended Foster Care; and I have documentation. Option 2: Income Verification Documents Federal Taxes I filed general taxes for last year I am an individual filing jointly; I am providing ONE 1040 form We filed more than ONE tax form in our household We are providing multiple 1040 forms I did not file federal taxes for last year. Current Income My household income has changed since I filed taxes last year Documents showing two months of income (including pay stubs or documentation of government assistance) Total Annual Household Income Document Upload Upload copies of your Fast Track Qualifying Document or Federal Taxes/Income Documentation Maximum 3 files.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Additional Documents Maximum 3 files.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Tell Us More Use this space to include any additional information or extenuating circumstances that were not included on this application. I can afford to pay a month I want/need a YMCA Open Doors Scholarship because 5. Signature Membership: Every member over the age of 12 must have his/her photo on file with the YMCA and must show their valid YMCA access card to enter the YMCA facility. If a member has forgotten their card they must show a photo ID to be manually checked in or be accompanied by an adult 18 years of age and over. A Release & Waiver of Liability and Indemnity Agreement must be signed for all Facility Memberships. Nationwide Membership: By participating in the YMCA Nationwide Membership Program (the “Program”), I agree that Channel Islands YMCA may share my YMCA membership information (e.g., [name, address, telephone number, e-mail address, date of birth and membership status]) with the National Council of Young Men’s Christian Associations of the United States of America and its independent and autonomous member associations in the United States and Puerto Rico (collectively, “Y-USA”) for purposes of my participation in the Program. Changes in Membership: Any cancellations, billing information updates, payment or membership changes require written notification 30 days prior to your next draft date. All provisions of the Membership Agreement remain valid and in force regardless of payment, billing or membership changes. If a membership is canceled during a program, program member rates will be charged for said program. The YMCA reserves the right to change membership fees. You will be notified 30 days in advance if fees are scheduled to change. It is the responsibility of the member to keep all payments to the YMCA current. If your YMCA account balance becomes more than 60 days overdue, your account will be handed over to a 3rd party account management company. Photographic and Video Release: In exchange for good and valuable consideration, the adequacy of which is hereby acknowledged, I hereby give Channel Islands YMCA, its volunteers, employees and any other person and entity acting with its permission the right to take, copyright, use, and publish any photographs or video of me or my child/children for the purpose of any YMCA advertising, promotion, or other purpose consistent with the YMCA mission. I agree that any such photograph or video is the property of the Channel Islands YMCA, and I hereby waive all rights thereto. I further waive any right to inspect or approve any printed or electronic material that may be used in conjunction with the photographs or video, or to approve the use to which the photographs or video may be applied. Identification and SOR Screening: Membership at any Channel Islands YMCA branch requires each individual over the age of 18 to provide at least one legal picture identification at the time of enrollment. Acceptable means of identification are: Drivers License, State Identification Card, Passport, School Identification Card, or Military Identification. At time of membership enrollment, and as needed, a photo of each individual will be captured and added to the membership record. The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access. The YMCA reserves the right to deny access or membership to any person who has been convicted of any crime involving sexual abuse, is or has been a registered sex offender. The YMCA reserves the right to conduct background checks on current and prospective members. I have read and agree to all policies stated above. This Application May Be Reviewed Every Year. 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 YMCA 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. Signature Signature of person completing the form Note that incomplete applications, or applications submitted without proper supporting documentation, cannot be reviewed. Payment plans are available. All records are kept confidential. Applications take up to two weeks to process. Scholarship awards expire 30 days from the date of this award notification. If your scholarship is not accepted within that time you will need to reapply. Once approved, your scholarship/discounted rate is valid from the date of approval to 12 months thereafter.
1. Applicant Information Name First Middle Last Date of Birth Gender - Select -MaleFemale Email Address Email Address Confirm Email Address Mailing Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Home Phone Cell Phone If an applicant is under 18, Parent's or legal guardian's name YMCA Location - Select -Camarillo Family YMCALompoc Family YMCAMontecito Family YMCASan Luis Obispo County YMCASanta Barbara Family YMCAStuart C. Gildred Family YMCAVentura Family YMCAYouth and Family Services YMCA, St. George Youth Center Emergency Contact Information Emergency Contact Name First Last Relationship Phone 2. All Additional Persons Living in this Household Place a check mark for each family member applying for assistance Yes Name DOB Gender Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female Yes Name DOB Gender Male Female 3. I Am Applying For Membership Teen Adult Family Senior Two Person Program Youth Activities Day Camp Sleepaway Camp Childcare(not available in all locations) Preschool(not available in all locations) Other Please specify program For Child Care and Camp Applicants Only What other child care options are available to you? Parent/Guardian #1 At Home Working In School Parent/Guardian #2 At Home Working In School 4. Please Provide the Following Documents Option 1: Fast Track Qualifying Document My household is enrolled in a federal, state or local government assistance program for food, housing or childcare such as CalFresh, SNAP, WIC, Medi-Cal, TANF, CSFP, HUD Voucher, Extended Foster Care; and I have documentation. Option 2: Income Verification Documents Federal Taxes I filed general taxes for last year I am an individual filing jointly; I am providing ONE 1040 form We filed more than ONE tax form in our household We are providing multiple 1040 forms I did not file federal taxes for last year. Current Income My household income has changed since I filed taxes last year Documents showing two months of income (including pay stubs or documentation of government assistance) Total Annual Household Income Document Upload Upload copies of your Fast Track Qualifying Document or Federal Taxes/Income Documentation Maximum 3 files.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Additional Documents Maximum 3 files.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Tell Us More Use this space to include any additional information or extenuating circumstances that were not included on this application. I can afford to pay a month I want/need a YMCA Open Doors Scholarship because 5. Signature Membership: Every member over the age of 12 must have his/her photo on file with the YMCA and must show their valid YMCA access card to enter the YMCA facility. If a member has forgotten their card they must show a photo ID to be manually checked in or be accompanied by an adult 18 years of age and over. A Release & Waiver of Liability and Indemnity Agreement must be signed for all Facility Memberships. Nationwide Membership: By participating in the YMCA Nationwide Membership Program (the “Program”), I agree that Channel Islands YMCA may share my YMCA membership information (e.g., [name, address, telephone number, e-mail address, date of birth and membership status]) with the National Council of Young Men’s Christian Associations of the United States of America and its independent and autonomous member associations in the United States and Puerto Rico (collectively, “Y-USA”) for purposes of my participation in the Program. Changes in Membership: Any cancellations, billing information updates, payment or membership changes require written notification 30 days prior to your next draft date. All provisions of the Membership Agreement remain valid and in force regardless of payment, billing or membership changes. If a membership is canceled during a program, program member rates will be charged for said program. The YMCA reserves the right to change membership fees. You will be notified 30 days in advance if fees are scheduled to change. It is the responsibility of the member to keep all payments to the YMCA current. If your YMCA account balance becomes more than 60 days overdue, your account will be handed over to a 3rd party account management company. Photographic and Video Release: In exchange for good and valuable consideration, the adequacy of which is hereby acknowledged, I hereby give Channel Islands YMCA, its volunteers, employees and any other person and entity acting with its permission the right to take, copyright, use, and publish any photographs or video of me or my child/children for the purpose of any YMCA advertising, promotion, or other purpose consistent with the YMCA mission. I agree that any such photograph or video is the property of the Channel Islands YMCA, and I hereby waive all rights thereto. I further waive any right to inspect or approve any printed or electronic material that may be used in conjunction with the photographs or video, or to approve the use to which the photographs or video may be applied. Identification and SOR Screening: Membership at any Channel Islands YMCA branch requires each individual over the age of 18 to provide at least one legal picture identification at the time of enrollment. Acceptable means of identification are: Drivers License, State Identification Card, Passport, School Identification Card, or Military Identification. At time of membership enrollment, and as needed, a photo of each individual will be captured and added to the membership record. The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access. The YMCA reserves the right to deny access or membership to any person who has been convicted of any crime involving sexual abuse, is or has been a registered sex offender. The YMCA reserves the right to conduct background checks on current and prospective members. I have read and agree to all policies stated above. This Application May Be Reviewed Every Year. 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 YMCA 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. Signature Signature of person completing the form Note that incomplete applications, or applications submitted without proper supporting documentation, cannot be reviewed. Payment plans are available. All records are kept confidential. Applications take up to two weeks to process. Scholarship awards expire 30 days from the date of this award notification. If your scholarship is not accepted within that time you will need to reapply. Once approved, your scholarship/discounted rate is valid from the date of approval to 12 months thereafter.