SCHOLARSHIP APPLICATION

Please return completed applications to:
Scholarship Services, 92nd Street Y
1395 Lexington Avenue
New York, NY 10128
For more information, call 212.415.5699,
or email .

All applications must include financial documentation.

Applications are due at least three weeks before

the start date of the program requested.

Applicant/Parent Information

Name Birth Date

Address

City, State, Zip

Place of Employment Occupation How Long?

Home Phone Work Phone Cell Phone

E-Mail Address

If request is for a child: Child’s Name Birth Date

Name of School Current Grade

Program Request (Do not use this application for summer camp programs)

Program Title ______

Day(s) Start Date Time Fee $

Have you participated in this program previously? If so, when

Scholarship Request

We urge you to plan carefully as all scholarships are partial and you will need to pay the balance of all program fees.

What are you able to pay for this program?

(Your application will be returned if an amount is not indicated)

Reason for request (please be specific)

Please provide any additional, relevant information, including unique circumstances

Financial Information

All applications must include a rent receipt or maintenance and mortgage statement, as well as the following documentation of income:

·  1040/1040EZ or other 2011 Tax Return, with all schedules, W-2 and 1099 Forms and current 2012 pay stub

·  Public Assistance verification if applicable

·  Unemployment Insurance verification if applicable and most recent tax return

·  Social Security/SSI Income/ pension verification if applicable

·  School tuition or scholarship statements

ANNUAL INCOME – Gross annual income including all members of household

·  Salary/Earnings $

·  Alimony and Child Support $

·  Workers’ Compensation/Unemployment/Disability $

·  Interest, Dividends, Rental, Annuities, Insurance $

·  Social Security and/or Pension $

·  Financial Support from Relatives $

·  Other (specify) $

Total Household Income $

HOUSEHOLD INFORMATION

What 92Y Scholarship Assistance have you (or your family) received?

For which other programs this semester are you or your family requesting assistance?

Are you currently unemployed?

Have you been unemployed in the last two years?

Household Members:

Name / Relationship / Age / Occupation

EXPENSES

Monthly housing costs (rent or mortgage and maintenance)

If you are paying school tuition for your child, what are your fees?

(Attach any school tuition or scholarship information, if applicable)

If you have scholarship, what amount do you have?

If you have any additional unusually high expenses, please explain

APPLICANT/PARENT SIGNATURE DATE

INFORMATION FOR SCHOLARSHIP ASSISTANCE

Welcome to Scholarship Services at 92Y. Please read the following information carefully so we can respond to your request.

·  The application on the web site is for classes and programs registered at Sales and Customer Service. If you are applying for May or Sixty Plus membership, Goldman Center children’s programs (Noar, Nesher, camps, or nursery school), please call Scholarship Services, 212.415.5699, for the appropriate application.

·  Applications are due at least three weeks before the program start date so we have time to review and respond. Please allow extra time if you are applying during a holiday period.

·  Complete both sides of the application even if you received assistance in the past.

·  Please attach copies of all financial documents to your form. All applications should include a rent or mortgage receipt as well as the other income information described on the application form. If you are submitting more than one application, one set of documents is fine. We do not need social security or account numbers so please cross them out.

·  Program information can be found in the 92nd Street Y catalogs available in the Main Lobby or on our web site www.92y.org.

·  Applications should be returned in person at Customer Service in the main lobby or by mail.

·  You will be notified about your scholarship by phone or mail. You will then need to complete the registration process and pay the balance of your fees as well as the order processing fee by the acceptance deadline. We have many requests for assistance and will not hold your scholarship past this date.

·  If you have any questions or concerns, please call Scholarship Services, 212.415.5699 or email, .

Revised April 2012