NORTH TREASURE COAST CHAPTER
2506 17TH AVENUE
VERO BEACH, FLORIDA 32960
772-562-2549
Learn-To-Swim Program Scholarship Application
Requested Scholarship Amount: Full $________ Partial: $_________
Address: _________________________________ Birth Date: _________________
City: ________________________ State _______________ Zip: ____________
Phone: _______________________ Alternate Phone: _______________________
Parent or Guardian's Name: _____________________________________________
I confirm and attest that my family's annual income is: $ ________________. I have attached a copy of my W-2 from last year as verification of this statement. I understand that submitting false information with this application can result in my being financially obligated for the full amount of the swim lessons provided.
Signature of Parent/Guardian: ____________________________ Date: ___________________
To be completed by the Authorized Provider:
I verify that the above student has completed the required sessions necessary to complete the American Red Cross Swimming Level ___.
Instructor's Signature: _________________________ Date: ________________