Open Door Request Form

YMCA of Columbia-Willamette

Open Door Request Form
At the Y, strengthening the community is our cause. We believe that lasting personal and social change can only come about when we all work together to invest in our kids, our health, and our neighbors. With our core values of youth development, healthy living, and social responsibility in mind, the YMCA proudly offers the Open Door Program to qualifying families, children, and adults to obtain quality Health and Wellness services, Youth Programs, and Child Care.

All information submitted is confidential. Completion of this request form does not guarantee approval. Your completed request will be processed within 5 to 10 business days from date received. If you have questions, please reach out to your local branch. For additional information, visit our Open Door web page.

Primary Member

IF YOU ARE REQUESTING ASSISTANCE FOR SOMEONE UNDER THE AGE OF 18, one adult must be included on this application.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Additional Members - Please list all members living at primary member's address who will be participating in programs and/or will have an active membership.

Monthly Household Income

Combined from all sources of members 18 and older
To process your application in the most efficient manner, please include ALL required documents. Incomplete applications will result in delayed processing.

Please attach appropriate qualifying documents:
1. Two most recent pay stubs from all working adults in household.
2. Documentation of other assistance or income received.
3. Reduced or free lunch letter
Please attach income documentation and should accurately represent the total income stated.*

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1. Enter Total Income*
Income Source Examples | Wages, Unemployment, SSI/SSD, Food Stamps, SNAP/TANF, Child Support, Alimony, Housing Assistance, Student Loans, Other Sources of Income
Total number of people living on stated income?*
2. Does your child receive Reduced or Free Lunch? *
3. Personal Statement | Are there any other factors we should take into consideration in evaluating your need for support? If so, please attach statement here.

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Optional Information

Providing demographic information is optional, but helps us to better serve you
Gender
Race
Primary Language
Employer

Acknowledgement
The YMCA reviews requests annually; failure to submit a new request form will result in membership or program fees automatically moving to the full rate. If I have automatic monthly payments and my assistance expires, I understand that the full rate will automatically be withdrawn from my account. I understand it is my responsibility to reapply before the deadline given. I declare that the aforementioned statements, to the best of knowledge and belief, are true and correct. I agree to inform the YMCA of any changes in my financial status.
Signature*

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YMCA of Columbia-Willamette