{field:zip_1681316979692}/Guardian Full Name: {field:parent_guardian_first_name_1681843365440} {field:parent_guardian_last_name_1681843456345}

Relationship to Student: {field:relationship_to_student_1683737381688}

Student Full Name: {field:student_first_name_1681324973594} {field:student_last_name_1681326089407}

Student Date of Birth: {field:student_date_of_birth_1681325008587}

Student Age: {field:student_age_1681325045921}

Address:
{field:street_address_1681317123685}
{field:city_1681316967099}, {field:state_1683737392890} {field:zip_1681316979692}

Parent or Guardian Phone: {field:parent_guardian_phone_1681326588880}

Parent or Guardian Email: {field:parent_guardian_email_1681326595587}

Preferred Swim School: {field:do_you_have_a_preferred_swim_school_1717773142950}

Is the student afraid of water? {field:is_the_student_afraid_of_water_1681325126904}

Is there a pool at home? {field:is_there_a_pool_at_home_1683739143648}

Have you previously applied for a scholarship? {field:have_you_previously_applied_for_a_scholarship_1683737513792}

Who are you requesting a scholarship for? {field:are_you_requesting_a_scholarship_for_check_one_1683737548782}

How many people are in the household? {field:how_many_people_are_in_the_household_1683737621658}

Ages of Children: {field:ages_of_children_separate_different_ages_with_a_comma_1683737679656}

Do you have a child with a diagnosed disability? {field:do_you_have_a_child_with_a_diagnosed_disability_1683737729004} {field:if_yes_to_the_above_what_is_the_disability_1683737767808}

Do you receive any of the following State of Florida benefits? {field:do_you_receive_any_of_the_following_state_of_florida_benefits_please_check_all_that_apply_1683737803017} {field:if_other_please_list_below_1683737966743}

Annual household income level? {field:annual_household_income_level_1683737989889}

{field:html_1681320939930}

By checking the box below, you agree to contribute a portion of the cost of swim lessons above and beyond the amount FLDPF can reasonably subsidize for Basic Survival Swim Lessons. Since every swim school charges a different price, FLDPF will make every effort to work with the swim school to receive reduced rates in order to make lessons more affordable.

Scholarship recipients must attend ALL classes during the designated class session. Failure to attend will result in dismissal and no future assistance.

Parent Responsibility: A parent must register for swim lessons with the swim school or pool within 60 days of the award of the scholarship or you will lose the scholarship. Each parent is responsible to inform Florida Drowning Prevention Foundation if there is a health issue with the student. It is also the parents responsibility to arrange transportation to and from the lessons. Parents will also follow all instructions given by the instructor/facility where the lessons are given.

Photo/Video Release: By accepting a scholarship from Florida Drowning Prevention Foundation you are giving consent for yourself and/or your child to be photographed by Florida Drowning Prevention Foundation or one of its agents while participating in the swimming lessons. This may be used for advertising or promotional pieces.

Liability Release: I expressly acknowledge, on behalf of myself and my heirs, that I will assume the risk of any and all injuries and illness as a result of participation in the swimming lessons. I realize that Florida Drowning Prevention Foundation is simply providing financial support in order to receive Basic Survival Swimming Lessons.

Medical Requirements: Some medical conditions may require a physician or therapist note for participation in the programs. Please make the instructor/facility aware of any potential issues.

By checking the box below, you are acknowledging that you have read and agree with the release information above and wish to accept a swimming scholarship from Florida Drowning Prevention Foundation if one is offered.

Check the box to acknowledge that you agree to the statement above: {field:yes_i_agree_1681318103343}

Student Registration & Swim Scholarship

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