Diabetes Prevention Program Financial Assistance

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YMCA Financial Assistance for Diabetes Prevention Program

Please complete the form below honestly and accurately. The YMCA reviews each application individually.

We use a sliding fee scale based on total household income and the number of household members. We require supporting documentation to verify household size and income, and we consider special circumstances when providing assistance.

We understand that your financial records may not reflect the full picture of your financial needs. Please include any and all information you consider relevant to your current situation.

Recipients are expected to be responsible for a percentage of the program fees.

At the end of the form, you will be asked to upload your current federal tax returns.

Important

The YMCA of the Triangle provides financial assistance for people living in our region, including Chatham, Durham, Johnston, Lee, Orange, and Wake counties in North Carolina.

Adult Information

First Name

Last Name

Date of Birth

Gender

Phone

Street Address

Apt. Number

City/Town

State

Zipcode

YMCA

Occupation

Length of Employment

Is there another adult living in the same household?

First Name

Last Name

Suffix

Date of Bith

Gender

Is there a child or dependent living in the home?

Dependent Information

Please list all the dependent children in the household. Tax forms must reflect those whom you list below.

First Name

Last Name

Child Date of Birth

Child Gender

Grade

Do you need to add another child?

First Name

Last Name

Date of Birth

Gender

Grade

Do you need to add another child?

First Name

Last Name

Date of Birth

Gender

Grade

Do you need to add another child?

First Name

Last Name

Child Date of Birth

Gender

Grade

Your Story

Please share your reasons for applying for YMCA financial assistance. Please include any and all relevant details about recent life changes or anything you deem important.

For example, a recent separation, job loss, or caring for an elderly parent.

Please share your story

Tax Returns

Please submit your 2024 or 2025 federal tax returns (Form 1040 pages 1 and 2 only, or 1040 EZ).

If you do not file federal income taxes, please call 1-800-TAX-FORM (1-800-829-1040) for verification of non-filing or visit IRS.gov for additional information.

If you are unemployed, draw social security, or are a full-time student, please provide a summary of your unemployment benefits, SSI paperwork, or financial aid benefits and student schedule.

You may upload up to four files. Please make sure you have marked over personal data information such as social security numbers.

Supporting Files

One file only.
5 MB limit.
Allowed types: gif, jpg, png, pdf.

Y Health Program Information

YMCA financial assistance is currently available for the Diabetes Prevention Program.

Program Selection

Agreement

I certify that this information is true and complete to the best of my knowledge. I grant permission to the YMCA to verify this information. I agree to notify the YMCA if my financial status should change.

Type in your name to indicate you agree with the above statement.

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