Student Registration & Swim Scholarship
Fields marked with an * are required.
Must be completed by a parent or guardian. One application for each child.
Florida Drowning Prevention Foundation is providing Basic Swimming Lessons for your child in the hope we can prevent another drowning death. Thank you for taking this important first step in saving a life.
Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
*
example@example.com
Do you have a preferred swim school?
Is the student afraid of water?
*
Yes
No
Is there a pool at home?
*
Yes
No
Have you previously applied for a scholarship?
*
Yes
No
How did you hear about FLDPF?
*
Social Media
Online Search
Referral
Other
Are you requesting a scholarship for:
*
Yourself
Your Child or Children
A Family Member
How many children are in the household?
*
Ages of Children
*
Separate different ages with a comma
Do you have a child with a diagnosed disability?
*
Yes
No
What is the disability?
Do you receive any of the following State of Florida benefits?
Florida Medicaid
Florida Food Assistance Program
Free School Breakfast/Lunch
WIC
Section 8 Housing
Florida Summer Food Service
Florida Head Start
Florida Special Milk Program
Other
Annual household income level?
*
$5,000-$25,000
$25,001-$30,000
$30,001-40,000
Over $40,000
Submit
Should be Empty: