Swim Lessons Scholarship Application

One with the Water is pleased to offer scholarships to qualified individuals. The amount of the scholarship depends on your individual circumstance. Please assist the Scholarship Committee in determining your eligibility by completing the following application.

Once we have received your application we will request a copy of your most recent tax return and/or proof of participation in the California School Lunch Program.

All information submitted is confidential; we do not sell, share, or distribute any information submitted.

Scholarship Form

Applicant

First Name *

Last Name *

Address *

City: *

State *

Zip *

Birthdate: *

Age: *

School: *

1. Does child participate in the California School Lunch Program? *

YES

Household Income

List all household members and income received in the last full month.

Name of household member #1:

Monthly job earnings before deductions:

Social security, pension or disability:

Other monthly income received:

Welfare (AFDC) child support or alimony:

Total monthly
income:

Name of household member @2:

Monthly job earnings before deductions:

Social security, pension or disability:

Other monthly income received:

Welfare (AFDC) child support or alimony:

Total monthly
income:

Name of household member #3:

Monthly job earnings before deductions:

Social security, pension or disability:

Other monthly income received:

Welfare (AFDC) child support or alimony:

Total monthly
income:

Name of household member #4:

Monthly job earnings before deductions:

Social security, pension or disability:

Other monthly income received:

Welfare (AFDC) child support or alimony:

Total monthly
income:

Briefly explain how swim lessons will benefit the child.

Parent or Guardian

First Name *

Last Name *

Email *

Phone *