Fee Adjustments

The Boro Park Y is a community-based agency, and it is our goal to serve all the members, from infants through senior adults.

In the case of financial difficulty, scholarships may be arranged confidentially. There are no government funds to cover membership, and we ask all members who are applying for a scholarship to complete the forms entirely and truthfully. The scholarships offered are modest, to enable us to provide assistance to as many people who apply. Please submit the forms with as much information as you can provide so that the committee can treat your application with respect and consideration.

Family Name
Telephone Number
Address 2
Zip Code
I am requesting an Adjusted Fee for the following type of Boro Park Y membership (Please Check. These are the only membership categories for which scholarships are available)
 Adult Individual
 Individual Child
 Adult Couple
Number of children in family
How many attend Yeshivas?
INCOME (Before taxes and other deductions)
Husband's annual gross income from salaries and wages
Husband's annual gross income from other sources
Wife's annual gross income from salaries and wages
Wife's annual gross income from other sources
Sources of Income (Other than salaries and wages)
Dividends/Insurance (in dollars per annum)
Unemployment Insurance (total dollar amount per week)
Length of Unemployment Insurance (date range)
Alimony/Support (total dollar amount per month)
Social Service Support (total dollar amount per month)
Social Security Support (total dollar amount per month)
Any other sources of income, including family and/or community support
Do you own your own home?
If "Yes," is it a single or multiple family dwelling?
 Single Family
 Multiple Family
Monthly carrying charges (total dollar amount)
Monthly rental income (total dollar amount)
If you rent your home, what is your total monthly rental cost?
If you own car(s), please provide the year and make of each car
Total annual Yeshiva/private school tuition bill for this year
Are you a current member of the Boro Park Y?
Have you ever previously applied to the Y for an Adjusted Fee?
Electronic Signature (by entering your name and submitting this application, you hereby certify that the information given is correct)
Date of Application

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move