ApplicationParent-Legal Guardian InformationUnique IDParent-Legal Guardian Name(Required) First Last Parent-Legal Guardian Date of Birth(Required) MM slash DD slash YYYY Parent-Legal Guardian Phone(Required)Parent-Legal Guardian Email (all communication will go here)(Required) Enter Email Confirm Email Parent-Legal Guardian Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you own or rent your home?(Required) Own RentSpouse-Partner Name First Last Spouse-Partner Date of Birth MM slash DD slash YYYY Spouse-Partner Email Enter Email Confirm Email DROWNING IN THE FAMILY(Required)*HAS YOUR CHILD EXPERIENCED A DROWNING, EITHER FATAL OR NON-FATAL (THAT REQUIRED AT LEAST ONE-NIGHT IN HOSPITAL) ? MUST BE YOUR CHILD; NOT A RELATIVE. YES NODROWNING EXPLANATIONIF THE ANSWER IS YES, PLEASE INCLUDE DETAILS OF THE EVENT LIKE NAME OF CHILD, DATE OF EVENT, AGE OF CHILD, CIRCUMSTANCES OF THE DROWNING.Legal DependentsDependents InformationClick "Add Dependent" button to add each child Row ID Legal Dependent Name Date of Birth Legal Dependent Gender Will Legal Dependent Receive Lessons? Legal Dependent New or Refresher Course?Actions EditDelete There are no Dependents. Add Dependent Maximum number of dependents reached. Employment InformationEmployersPlease list your employer's information.EmployerSupervisorEmployer PhoneLength of employmentPositionWeekly Hours Add RemoveSpouse-Partner EmployersPlease list your souse-partner employer's information.EmployerSupervisorEmployer PhoneLength of employmentPositionWeekly Hours Add RemoveMONTHLY HOUSEHOLD INCOME (before taxes) *(Required)IMPORTANT: ENTER GROSS MONTHLY AMOUNT BEFORE TAXES HAVE BEEN TAKEN OUT. NOT YEARLY & NOT NET.OTHER INCOME (Child Support, Public Asst) *(Required)FILED TAXES LAST YEAR?(Required) Yes NoIF NO TAXES FILED- EXPLAINGeneral InformationEver received Scholarship from Live Like Jake?Have you ever received a scholarship from the Live Like Jake Foundation, Inc.? Yes NoIf YES, please explainLessons Time Preference(Required) MORNING (8 am - 11 am) AFTERNOON (11 am - 4 pm) EVENING (4 pm - 7 pm) NO PREFERENCEPERMISSION FOR CHILD'S NAME IN PHOTOS(Required)PLEASE INDICATE IF WE MAY IDENTIFY THEIR NAME OR NOT. ONLY by first name, last initial and age MAY NOT be revealed in text in connection with the image(s)Have you taken a vacation/trip in the last 6 months?(Required) Yes NoIf YES, please explainAre you planning a vacation|trip in the next 6 months?(Required) Yes NoIf YES, please explainDo you currently have annual passes to any theme park?(Required) Yes NoIf YES, please explainHave you applied for a scholarship with another non-profit?(Required) Yes NoHOW DID YOU HEAR ABOUT US? Live Like Jake website Facebookj Instagram Friend Referral ISR Instructor Search Engine - Google, Bing, etc. OtherFRIEND OR OTHER REFERRAL'S NAMEALREADY SPOKEN TO SWIM INSTRUCTOR?(Required) Yes NoEnter instructor's namePLEASE NOTE that instructor must know you are applying for scholarship.If NO, please visit infantswim.com to ensure there is an ISR instructor in your area.WEEKLY AMOUNT YOU CAN AFFORD(Required)PLEASE DESCRIBE IN DETAIL WHY YOU NEED THIS SCHOLARSHIP(Required)PLEASE EXPLAIN WHY YOU HAVE A FINANCIAL NEED TO REQUEST THIS SCHOLARSHIP.*** UPLOAD REQUIRED DOCUMENTS BY USING THE "Drop files here or Select Files button" BELOW FOR EACH.*** APPLICATIONS WILL NOT BE PROCESSED UNTIL ALL REQUIRED DOCUMENTS ARE SUBMITTED ***A copy of the following documents MUST be provided to process the application. (For security measures please black out your SSN on all documents):Driver’s LicenseTwo current pay stubs (an additional two from your spouse/partner if applicable)Your most recent tax return (e.g. complete 1040 form, federal tax return, NOT your W2 form)Upload Your Files(Required)Upload your files in .pdf, .doc, .docx or .jpg format Drop files here or Select filesAccepted file types: pdf, doc, docx, jpg, Max. file size: 25 MB, Max. files: 10. IF APPLICABLE PLEASE INCLUDE:A “Did Not File” taxes form - PROOF REQUIREDSocial Security benefits statementDisability benefit statementUnemployment benefit statementChild Support statementUpload Your FilesUpload your files in .pdf, .doc, .docx or .jpg format Drop files here or Select filesAccepted file types: pdf, doc, docx, jpg, Max. file size: 25 MB, Max. files: 10. Terms and Conditions(Required)Terms and conditions placeholder. I agree to the terms and conditions.SignatureReset signature Signature locked. Reset to sign again
