2026 Community Access Membership Fund Application Step 1 of 3 33% LinkedInThis field is for validation purposes and should be left unchanged.General Application for Financial AssistanceHAC 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. New HAC members must complete their membership enrollment in-person with the front desk within 30 days of approval. Scholarships are awarded on a first-come, first-served basis and are subject to available funding, which is dependent on donations.Applicant InformationApplicant's Name(Required) First Last Applicant's Date of Birth(Required) MM slash DD slash YYYY Applicant's Phone Number(Required)Applicant's Email Address(Required) Applicant's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Household Member InformationFamily memberships include up to two adults, up to three students (ages 18-23), and up to six children (ages 0-17). Please add the names and dates of birth for all household members.Household Member #1 Name First Last Household Member #1 Date of Birth MM slash DD slash YYYY Household Member #2 Name First Last Household Member #2 Date of Birth MM slash DD slash YYYY Household Member #3 Name First Last Household Member #3 Date of Birth MM slash DD slash YYYY Household Member #4 Name First Last Household Member #4 Date of Birth MM slash DD slash YYYY Household Member #5 Name First Last Household Member #5 Date of Birth MM slash DD slash YYYY Household Member #6 Name First Last Household Member #6 Date of Birth MM slash DD slash YYYY Do you have additional household members to include on this application?(Required) Yes No Household Member #7 Name First Last Household Member #7 Date of Birth MM slash DD slash YYYY Household Member #8 Name First Last Household Member #8 Date of Birth MM slash DD slash YYYY Household Member #9 Name First Last Household Member #9 Date of Birth MM slash DD slash YYYY Household Member #10 Name First Last Household Member #10 Date of Birth MM slash DD slash YYYY Household Member #11 Name First Last Household Member #11 Date of Birth MM slash DD slash YYYY Household InformationHolland Aquatic Center is proud to offer financial assistance through the Community Access Membership Fund with support from the HAC Foundation. In order to apply for financial aid, your household must meet specific income criteria that are consistent with other area support services. Households with annual incomes less than or equal to the following guidelines may be eligible for financial assistance from HAC. Please note that this criteria is subject to change. 2 persons $42,300 | 3 persons $53,300 | 4 persons $64,300 | 5 persons $75,300 | 6 persons $86,300 | 7 persons $97,300 | 8 persons $108,300 | Each additional person add $5,500.Do you qualify under the income guidelines listed above?(Required)YesNoHow 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 additional documentation in order to complete this application. Please upload a copy of last year's federal tax return, along with either (a) two current pay stubs or (b) two Social Security or disability checks.(Required) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 5. Personal TestimonialIf you feel comfortable sharing, please let us know what membership at HAC means to you and your family. How would your family specifically benefit from this financial assistance?Please share your personal testimonial here. (OPTIONAL)May we share your testimonial with the donors who contribute to the Community Access Membership Fund? No, please do not share my story. Yes , but please keep me anonymous. Yes, but please use my first name only. Yes, you may include my full name. Terms and Conditions(1.) Membership is valid for 12 months from the date of registration. Participation beyond the 12-month term requires reapplication and is subject to availability of funds. (2) Participants must visit the Holland Aquatic Center at least 4 times per month per family unit. Usage may be reviewed, and future scholarship eligibility may be based on participation. (3) A valid credit card is required and must be kept on file. Participants agree to an automatic charge of $15 per month for the duration of membership. Failure to maintain a valid payment method may result in suspension or termination of benefits. (4) Benefits are non-transferable and may only be used by approved members. (5) Participants must comply with all Holland Aquatic Center rules, policies, and codes of conduct. Failure to do so may result in membership termination and future ineligibility.Acknowledgement of Terms and Conditions I understand and agree that my Community Access Membership may be suspended or terminated if I fail to meet the program requirements outlined above.
