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Income-Based Membership Acceptance Form


I am accepting a membership scholarship from the Family YMCA of Marion & Polk Counties. I have read and understand the following acceptance terms:


  • This scholarship is awarded in part from the generous donors and supporters of the Family YMCA of Marion & Polk Counties.
  • If my financial situation improves and I am able to pay more, I will notify the YMCA so that my account can be reevaluated. This will allow the YMCA to help others that are also in need.
  • Based on my current situation (verified with Federal Tax Return or other approved Income/Household documents) the YMCA is able to approve me for:

Membership Type:
Joiner’s Fee:
Monthly Rate:


  • In the event of future YMCA membership rate increases, the YMCA will attempt to notify all members. If the rate increase is a hardship for me, I am able to make an appointment with the CEO or the Membership Director to discuss my options.
  • At this time, YMCA staff will only approve members on my membership that are included on my federal tax return(s) or other approved verification documentation.
  • To add members in the future to my membership I must provide documentation verifying income and proof of residence in the household.
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Discount Group Added

Income Based Membership

What is Income Based Membership?

Income Based Membership is a reduced rate for your monthly YMCA membership. We have two categories for scholarship which are determined by your household income.

How does the YMCA offer Income Based Membership scholarships?

Part of our mission is to “never turn anyone away due to the inability to pay”. Therefore, the YMCA offers these scholarships in part from the generous donors and supporters of the Family YMCA of Marion & Polk Counties. Ask us more about donating to the “We Believe Campaign” to contribute to this worthy cause!

How do I apply for an Income Based Membership scholarship?

Simply bring in this year’s Federal Tax Return to the YMCA and our Front Desk staff can determine your scholarship amount on the spot!

What if I haven’t filed taxes?

If you are exempt from filing taxes, you may still be eligible for a scholarship from the YMCA. Simply schedule an appointment with the Membership Director of CEO and they can sit down with you to work with you on a personalized scholarship based on your situation. At that meeting you will need to bring alternative documentation to show proof of household income and residents/dependents.


Household Income








$60,000 +
Adult Membership $38 $50 $61
Family Membership $50 $66 $82
Teen Membership $36 $36 $36

College Membership

$36 $46 $46
Senior Membership $38 $50 $55
Senior Couple Membership $50 $66 $75


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