YMCA Club Membership Voucher Request Form

*ONE FORM PER FAMILY*
Member or Member’s parent/guardian must fill out this section. Please print.

Member Name:

Street:

City:

State:

County:

Phone Number:

Email:

CareSource ID Number

This number is found on the front of your Member ID Card.

Date of Birth:

Voucher for Club:

Club Name:

Club’s Street:

City:

State:

Please remember, that to qualify for the YMCA voucher you MUST meet all these requirements:
1) One well-visit.
2) One dental visit.
3) Be an eligible CareSource Member.

We will send a letter letting you know if you are eligible for the YMCA voucher. You should get this within 7 to 14 business days of filling out this form.

GA-MED-M-3083663 DCH Approved: 7/23/2024