Scholarship Application

* Indicates required field

Head of Household Requesting Assistance *

First

Last

Number of adults who reside in the home *

1 2 3 More

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Your Occupation *

Are you currently employed? *

Yes No

Employer's Name *

Total Household Monthly Income *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Dependent for whom you are requesting a scholarship *

Choose One *

Male Female

Wages *

Unemployment *

Child Support/Alimony *

Food Stamps *

Pension/Retirement *

Other *

Upload Current proof of participation in WIC, Head Start, Peachcare for Kids, or Medicaid OR a recent pay stub or a copy of last year’s Federal Tax Return *

Max file size: 20MB

I affirm to the best of my knowledge that the above information is true and complete. I agree to provide assistance or income documentation as requested, thereby completing the application. I understand this financial assistance is short term and will be reviewed regularly.

Swim Beyond the Boundaries Inc. Swim Scholarship Application ​

Swim Beyond the Boundaries Inc. Swim Scholarship Application