Membership Assistance Application

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Have you ever been a member of the YMCA of Fredericton?

If so, have you previously received Membership Assistance?

Please provide a brief explanation of your current financial situation (i.e. unemployed, reduced income, medical expenses, etc.)

Please indicate name, age, date of birth and whether they will be included in the membership

Income (yourself) *

Income (spouse)

EI Benefits

Social Assistance Benefits

Child Support/Spousal Support

Canada Child Tax Benefit

Student Loan

Savings

Other (please specify)

Total Income (per month) *

Please list any special/extraordinary expenses per month .

Please provide the TOTAL ($) of the expenses per month.

Type Name *

First

Last

Date *

Please upload proof of TOTAL HOUSEHOLD income here *

Click or drag a file to this area to upload.