Application for ScholarshipUnique IDLive Like Jake Foundation, Inc. was created by Keri and Roarke Morrison in honor of their son, Jake Morrison, who passed away as the result of a tragic drowning accident. The Foundation’s mission is to promote childhood drowning awareness and water safety. In order to accomplish this, we encourage self-rescue swim lessons. We try to help minimize the cost of the lessons for those in financial need by granting scholarships. Please note these scholarships are for families that truly cannot afford the lessons.ELIGIBILITYAssistance is granted based on financial need. We consider household income and number of legal dependents as the primary criteria. While we understand that monthly expenses can be extensive, it is impossible to base scholarship awards on each individual budget.We believe that a sense of ownership is developed if the participant contributes to the cost of his/her involvement. Therefore, scholarship recipients may pay a percentage of the program fees.Scholarships are granted for one session for up to 6 weeks of lessons. Upon expiration, the recipient must reapply. The original scholarship application information is valid for 6 months after original approval.HiddenApp Status Approved Denied Under Review OtherSet New User Login CredentialsEmail (will serve as username)(Required)Password(Required)Make strong, not easy to guess. Enter Password Confirm Password Strength indicator Parent or Legal Guardian InformationParent-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 Does a Spouse or Partner live with you?(Required) Yes NoSpouse-Partner Name(Required) First Last Spouse-Partner Date of Birth(Required) MM slash DD slash YYYY Spouse-Partner Email(Required) Enter Email Confirm Email Do you own or rent your home?(Required) Own Rent OtherDo you have a pool at your residence? Yes with pool fence Yes but NO pool fence NoDROWNING 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 DependentsNumber of Legal Dependents(Required) 1 2 3 4 5 6 7 8Dependents Legal Dependent NameActions EditDelete There are no Entries. Add Entry Maximum number of entries reached. Employment InformationEmployment Status Employed Full-Time Employed Part-Time Self-Employed Unemployed OtherEmployersPlease list your employer's information.EmployerSupervisorEmployer PhoneLength of employmentPositionWeekly Hours Add RemoveSpouse-Partner Employment Status Employed Full-Time Employed Part-Time Self-Employed Unemployed OtherSpouse-Partner Employers(Required)Please 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)FILED TAXES LAST YEAR?(Required) Yes NoIF NO TAXES FILED- EXPLAINGeneral InformationEver received Scholarship from Live Like Jake? Yes NoIf YES, please explainLessons Time Preference(Required) MORNING (8 am - 11 am) AFTERNOON (11 am - 4 pm) EVENING (4 pm - 7 pm) NO PREFERENCEHave 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 Facebook Instagram Friend Referral Search Engine - Google, Bing, etc. Swim Instructor OtherFRIEND OR OTHER REFERRAL'S NAMESWIM INSTRUCTOR'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.TOTAL WEEKLY AMOUNT YOU CAN CONTRIBUTE(Required)PLEASE DESCRIBE IN DETAIL WHY YOU NEED THIS SCHOLARSHIP(Required)*** 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)Do you have a valid Driver's License?(Required) Yes No OtherUpload your Driver’s LicenseUpload 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. Do you have 2 current pay stubs (an additional 2 from your spouse/partner if applicable)?(Required) Yes No OtherUpload 2 current pay stubs (an additional 2 from your spouse/partner if applicable)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. Do you have your most recent tax return (e.g. complete 1040 form, federal tax return, NOT your W2 form)?(Required) Yes No OtherUpload your most recent tax return (e.g. complete 1040 form, federal tax return, NOT your W2 form)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. PLEASE READ THE FOLLOWING AND SIGN BELOW:(Required)MUST SCROLL TO THE END: I hereby certify that the information in this application is true, accurate and complete to the best of my knowledge. I am aware that it is my responsibility to notify Live Like Jake Foundation, Inc. in writing of any change in the information supplied on this application, as it may affect my eligibility for financial assistance. I understand that every part of this application must be completed and that I must provide adequate proof of income in order for my application to be processed. I understand that incomplete applications cannot be processed. I agree to the Terms of ServiceSignature(Required)Today's Date(Required) MM slash DD slash YYYY Spouse/Partner Signature(Required)Today's Date(Required) MM slash DD slash YYYY RELEASE OF LIABILITY AND INDEMNITY AGREEMENT(Required)MUST SCROLL TO THE END: I, on behalf of myself, my child, my heirs, executors, administrators, successors, and/or assigns, as a condition of receiving financial support from Live Like Jake Foundation, Inc. for my child to participate in self-rescue swim lessons, waive all claims for any personal injury, death, loss of health, financial loss or damage to property occurring during, or as the result of my child’s participation in self-rescue swim lessons. Furthermore, I indemnify, hold harmless and affirmatively release Live Like Jake Foundation, Inc., its program staff and their affiliates, principals, employees and/or agents for any such loss, damage, injury or liabilities. This release of liability includes any claims made against Live Like Jake Foundation, Inc. related to my child’s participation in self-rescue swim lessons with an independent instructor. I understand risks are associated with self-rescue swim lessons. I waive all claims against the Foundation as described above without limitation. I agree to the Terms of Service“DID NOT FILE” TAXES FORM (IF APPLICABLE)I did not file a Federal tax return for the year because my income level (which excludes social security income) was below the Federal Filing requirements. I agree to the Terms of ServiceEnter year most recent year you did not file taxes(Required)Signature(Required)Today's Date(Required) MM slash DD slash YYYY Spouse/Partner Signature(Required)Today's Date(Required) MM slash DD slash YYYY PERMISSION FOR CHILD'S NAME IN PHOTOS(Required)PLEASE INDICATE IF WE MAY IDENTIFY THEIR NAME OR NOT. ONLY by first name and age MAY NOT be revealed in text in connection with the image(s)DIGITAL RELEASE FORM FOR MINOR CHILDRENMUST SCROLL TO THE END: I, being the Parent/Legal Guardian, hereby consent to the use of images, depictions, and recordings notated below of the above named minor by Live Like Jake Foundation Inc. their assigns or successors at its sole discretion. I, with my signature below, acknowledge that such photographs, films, recordings and videos shall be the property of Live Like Jake Foundation, Inc. and they shall have the right to duplicate, reproduce, and make other uses of such media as notated below as they may desire free and clear of any claim whatsoever.• Photographs • Videotape • Digital images of my child for use in promotional or educational materials as follows: • Printed publications or materials • Electronic publications or presentations • Website (www.LiveLikeJake.com) • Facebook pagesI authorize the use of these images indefinitely without compensation to me. All prints, digital reproductions and video recordings shall be the property of Live Like Jake Foundation, Inc. I agree to the Terms of ServiceSignature(Required)Today's Date(Required) MM slash DD slash YYYY Spouse/Partner Signature(Required)Today's Date(Required) MM slash DD slash YYYY SCHOLARSHIP GUIDELINESMUST SCROLL TO THE END: The ISR program requires a 10- minute daily lesson for 5 days a week for approximately 4 to 6 weeks (or until the instructor deems the child is safe). You have to commit to this schedule in order to accomplish the desired results and agree to abide by the instructor’s guidelines and rules. Excessive cancellation of lessons is not acceptable and could result in termination of scholarship.Please note that ISR has a $105 registration fee for new students and $35 fee for existing students. The foundation WILL reimburse this fee when the lessons have been completed and all the scholarship guidelines have been followed.You MUST update Live Like Jake weekly with the progress of the lessons. This will enable the Foundation to share our success stories, spread the word about drowning prevention, and encourage more parents to sign up their children for these lifesaving skills. Please note that if the above mentioned in red is not completed, the scholarship can be revoked and future refresher applications will not be approved.We also ask that you participate or volunteer (if local) in one of our fundraisers/events we hold throughout the year. We have several annual events that participation can be from anywhere. These events are how we raise the money necessary to help your family and others. Please visit our Facebook page and website for upcoming events.Please sign below if you agree to the terms of the scholarship. I agree to the Terms of ServiceSignature(Required)Today's Date(Required) MM slash DD slash YYYY Spouse/Partner Signature(Required)Today's Date(Required) MM slash DD slash YYYY UntitledConfiguration RequiredUse the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.NameThis field is for validation purposes and should be left unchanged.
