YMCA - HPB - Health and Public Benefits - Family Information Form (2025-2026)
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  • Family Support Services Support Request

    YMCA of South Florida

  • Thank you for choosing the YMCA of South Florida to assist you with your public benefits application. We know that navigating the world of public assistance can be complex and, at times, overwhelming. That’s why we’re here — to guide you and support you every step of the way.

    To help us provide you with the best possible assistance, please complete the enclosed Family Information Form. The information you share will help us better understand your family’s needs and determine your eligibility for available public benefits and programs.

  • BENEFIT NEED

  • Select the benefit you are submitting this form for:*

  • ADULT INFORMATION

  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Is this a cell/mobile phone?*

  • CHILD/ YOUTH INFORMATION

    • CHILD/ YOUTH - 1 
    • Date of Birth*
       - -
    • Languages Spoken (mark all)*

    • We want to get to know your child better so that we can provide the best possible experience in our porgrams. Please tell us more about your child...

    • To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?
    • What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)*
    • Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do?*
    • What are the main ways in which your child communicates? (mark all that apply)*
    • What, if any, help does your child/youth receive at this time? (mark all that apply)*
    • CHILD/ YOUTH - 2 
    • Date of Birth*
       - -
    • Languages Spoken (mark all)*

    • We want to get to know your child better so that we can provide the best possible experience in our porgrams. Please tell us more about your child...

    • To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?
    • What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)*
    • Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do?*
    • What are the main ways in which your child communicates? (mark all that apply)*
    • What, if any, help does your child/youth receive at this time? (mark all that apply)*
    • CHILD/ YOUTH - 3 
    • Date of Birth*
       - -
    • Languages Spoken (mark all)*

    • We want to get to know your child better so that we can provide the best possible experience in our porgrams. Please tell us more about your child...

    • To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?
    • What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)*
    • Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do?*
    • What are the main ways in which your child communicates? (mark all that apply)*
    • What, if any, help does your child/youth receive at this time? (mark all that apply)*
    • CHILD/ YOUTH - 4 
    • Date of Birth*
       - -
    • Languages Spoken (mark all)*

    • We want to get to know your child better so that we can provide the best possible experience in our porgrams. Please tell us more about your child...

    • To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?
    • What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)*
    • Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do?*
    • What are the main ways in which your child communicates? (mark all that apply)*
    • What, if any, help does your child/youth receive at this time? (mark all that apply)*
    • (YMCA) Financial Assistance Application for After-School/ Summer Services 

    • Instructions for Completing the Financial Assistance Section

      1. Provide Detailed Information: Carefully fill out the Financial Assistance section. Your responses help us understand your household circumstances and are crucial in assessing your application.
      2. Submit the Application: Once you have completed the section, submit your application. This will initiate the review process to determine your eligibility for financial assistance.
      3. Await Notification: After your application has been reviewed, we will notify you in writing regarding the outcome. If approved, this notification will include details of the financial assistance awarded to you.

      Please ensure that all information provided is accurate and complete to facilitate a smooth review process.

    • Start Date:*
       - -
    • Rows
    • Select the required documentation update that you will upload below:*
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    • FINANCIAL ASSISTANCE

      Financial assistance is granted based on available funds. Applicants must submit a completed Financial Assistance Application with all required documentation for YMCA approval before any fee adjustments are made. Regular program fees apply until you receive official confirmation of your award from the YMCA.

      The YMCA reserves the right to end financial assistance at any time, especially if monthly payments are more than 10 business days overdue. If funds are unavailable, applicants may be placed on a waiting list. Incomplete applications will not be considered.

    • Agreements*
    • Award Effective Date
       - -
    • Award Expiration Date
       - -
    • Acknowledgement 

    • ACKNOWLEDGEMENT 

      Thank you for completing this form. We want to assure you that your application is important to us and will be thoroughly reviewed by our team. Upon completion of the review process, one of our dedicated staff members will reach out to you to assist with your inquiry. We are committed to guiding you through every step to ensure you receive the assistance you need.

      CONSENT

      As part of my and my child’s voluntary participation in this program, I give permission for the information collected to be submitted to The Children’s Trust for program evaluation and quality purposes. The Children’s Trust funds this program and follows strict data privacy protections, including Family Educational Rights and Privacy Act (FERPA) guidelines.

      Should you require immediate attention or have any urgent inquiries, please call the YMCA’s main line at 305-357-4000.

      For community resources, you may call the 211 Miami Helpline, visit 211miami.org, or learn more about The Children’s Trust programs at www.thechildrenstrust.org.

    • Date*
       - -
    • Should be Empty: