General Application for Financial Assistance

Application for Membership Financial Assistance

HAC is not just a fitness facility or a community pool - we have been a proud part of the Holland community since 1968. Our doors are open to everyone, no matter their age, abilities, or financial situation. If you are experiencing financial hardship or other extenuating circumstances, please complete this application so that a member of our team can determine your eligibility for financial assistance. All HAC members receive the same membership benefits, regardless of financial support needed. All financial information remains confidential. Please complete all fields below. Incomplete applications will not be considered; financial assistance is not guaranteed to all applicants, even if past approval has been granted. Financial assistance will be provided to one person per household per quarter. New HAC members must complete their membership enrollment within 30 days of approval.

Which membership category applies to you?(Required)

Adult (Single) Membership

Family Membership

Senior Membership

"Adult" is defined as one person age 18 or older. "Senior" is defined as one person age 62 or older. "Family" is defined as up to two adults living in the same home and their dependents of whom they have custody.

Applicant's Name(Required)

First Last

Applicant's Date of Birth(Required)

Applicant's Email(Required)

Applicant's Phone(Required)

Applicant's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Household Information

Households with annual incomes less than or equal to the following guidelines may be eligible for financial assistance from HAC. These income guidelines are provided by the US Department of Agriculture via the Michigan Department of Education. 2 persons $32,227 | 3 persons $40,626 | 4 persons $49,025 | 5 persons $57,424 | 6 persons $65,823 | 7 persons $74,222 | 8 persons $82,621 | for each additional family member add $8,399

Do you qualify under the income guidelines listed above?(Required)

How many people are in your household?(Required)

If this form is being completed by the head of household, please include yourself in this total.

What is your annual household income?(Required)

Note: You are required to submit supporting documentation to complete this application.

Please upload a copy of last year's federal tax return, along with either two current pay stubs OR two Social Security or disability checks.(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 5.

Your application will not be processed without supporting documentation. If you need assistance or have questions, please contact us at 616-393-7595.