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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.
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APPLICATION FOR ADJUSTED MEMBERSHIP FEE |
Family Name | |
Telephone Number | |
Address | |
Address 2 | |
City | |
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State
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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) |
Family
Adult Individual
Individual Child
Adult Couple
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Number of children in family | |
How many attend Yeshivas? | |
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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 | |
TOTAL GROSS INCOME | |
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Sources of Income (Other than salaries and wages) |
Dividends/Insurance (in dollars per annum) | |
Unemployment Insurance (total dollar amount per week) | |
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Length of Unemployment Insurance (date range)
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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? |
Yes
No
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If "Yes," is it a single or multiple family dwelling? |
Single Family
Multiple Family
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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 | |
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ANY OUTSTANDING EXPENSES OR DEBTS |
Total annual Yeshiva/private school tuition bill for this year | |
Are you a current member of the Boro Park Y? |
Yes
No
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Have you ever previously applied to the Y for an Adjusted Fee? |
Yes
No
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Electronic Signature (by entering your name and submitting this application, you hereby certify that the information given is correct) | |
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Date of Application
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