FEE ASSISTANCE Lagoon Pool

Recipient Name*

First Name

Last Name

Name of Parent of Guardian (If Under 16)

First Name

Last Name

Parent or Guardian Relationship (If Under 16)

Home Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Mobile Phone*

Home Phone*

Email*

Course or Programme Fee Assistance Is Required For*

Please Detail The Circumstances Surrounding Your Application For Fee Assistance*

Please Outline How Your Involvement In the Nominated Course Or Programme Will Benefit You/Your Family*

Are You A Current YMCA Member Or Do You Presently Use Any Other YMCA Services?*

Yes No

Have You Been A YMCA Member Or Used YMCA Services In The Past?

Yes No

Are You Able To Contribute A Portion Of The Programme/Course Fee?*

Yes No

What Portion Of The Programme/Course Fee Do You Feel Able To Contribute?

As part of your application we ask that you submit on one of the following in support of your application:

File*

No File Chosen

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