Somerville Y Scholarship Application

Please fill out our Scholarship Application below.

We are no longer taking new scholarship applications for our Childcare Summer Program

Scholarship recipients who have done well under this program are those who have:

• Been willing to help others that may be in need.

• Picking up things left out of place.

• Respect for yourself and others.

• Refrained from use of offensive language.

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Secondary Phone

Are you Applying as an individual or Family/Household *IndividualFamily Household

How Many Other Adults? *NoneOneTwoThreeFour

The Names of the Other Adults in the Household (1 Name Per Line Please) *

How many Children/Dependents *NoneOneTwoThreeFourFive or More

The Names and Ages of the Children/Dependent(s) in the Household (1 Name Per Line Please) *

Parent/Guardian #1: *

• At Home
• Working
• In School

Parent/Guardian #2 *

• At Home
• Working
• In School

Who has custody of the children *

• Joint
• Mom
• Dad
• Guardian
• Foster

Check all Memberships/Programs you are applying for *

• Youth Membership (6-13)
• High School Membership (14-18)
• Adult Membership
• Family Membership
• Child Care or Summer Program
• Swim Lessons
• Other

Please Specify Other: *

To Qualify, We need one of the Following:

Federal Tax Form from the Last Year *

• 1040 Tax Form for Individual or all household incomes
• Filed Jointly, Submitting One 1040
• Filed more than one tax form and we are providing Multiple 1040 forms
• I did not File last year/my household income has changed, submitting documents for last 30 days of Income

1040 or Income Documents *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Signature *

Clear Signature

Submit