Aquatics Application Form

Application/ Renewal for Aquatics Funding Program
(Application and renewal are the same form found below)

PLEASE VIEW CRITERA INFORMATION BEFORE COMPLETING FORM.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent/Guardian/Caregiver (If applicable)
Number of people in household
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Case Worker (If applicable)
Case Worker Contact Phone Number (If applicable)
How do you feel the Aquatic Sessions will benefit you and your diagnosis/ disability?
Our funding requires attendance of (4) four Aquatic sessions per month; do you anticipate attending more sessions? If so, how many times per month?

Please read and sign this release: I authorize the Special Needs Foundation of Des Moines County to release and obtain information about my participation in the Aquatics Program at SEIR Rehabilitation Center from my physician or SEIR Staff. This exchange may be verbal or written. The Special Needs Foundation will not release this confidential information to any other agency. I do agree to protect, indemnify, and save harmless the Special Needs Foundation of Des Moines Count and its Board of Directors, administrators, officers, employees, and agents from and against all losses, costs, attorney fees, damages, claims, and expenses occasioned by or arising out of any accident or other occurrence causing or inflicting injury and/or damage to any person or property, including the disabled persons using the pool under the Special Needs Foundation Program, happening or done in or about the swimming pool and the facilities immediately adjacent thereto or due directly or indirectly to the use or occupancy of the swimming pool or any part thereof or the facilities adjacent to the Special Needs Foundation and persons using the pool under this funding or any other persons claiming through or under the Special Needs Foundation or the swimmers.
Signature

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Date

MonthDayYear
Date
(Next page is regarding documentation of income, please continue and submit your documents with application.

*****PLEASE PROVIDE DOCUMENTATION OF INCOME***** SEE BELOW FOR APPROPRIATE DOCUMENTS
- Documentation from the Department of Human Services such as medical or food assistance or FIP qualification.
OR
- If an applicant does not receive services from DHS but still qualifies based on income (see chart below), the applicant must submit the most recent tax form with completed application.

*For households with more than 8 members, add $10,280 annually*

**Updated annually: These guidelines are for the year of 2024**
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Application/ Renewal for Aquatics Funding Program