Clone of PAL Scholarship Interest List

PAL Adaptive Swim Scholarship: for Low-Income Special Needs Families

This form places you on the PAL Scholarship Interest List. Once applications open, families will be notified by email and will need to provide documentation to verify eligibility for low-income support. Scholarships provide funding for adaptive swim lessons, helping children ages 3–18 build confidence, safety, and life-saving skills in and around the water.
This is the PAL Scholarship Interest List. Once you submit this form, you will receive an email notification when scholarship applications officially open May 1st.
I. Personal Data

Students Name
Full Name*

First NameLast Name
Birthdate*

MonthDayYear
MaleFemale
City/State/Zip*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Name*

First NameLast Name
Best Contact Number*
Format: (000) 000-0000.
Email *
Where the confirmation will be send to
YesNo
Additional Information

0/300
Applicant's E-Signature
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Signature*

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Name*

First NameLast Name
The PAL Program, the Greater Providence YMCA, and the Department of Health are proud to partner to provide equitable and inclusive access to adaptive swim education. Together, we ensure every child has the opportunity to build confidence, safety, and life-saving skills in the water.
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PAL Adaptive Swim Scholarship: for Low-Income Special Needs Families

I. Personal Data

Applicant's E-Signature