Tsunami Swimming

Scholarship Application

Name of Swimmer _________________________________________ Birthdate _______________

_______Free School lunch participant - Name of School ________________________________

_______Food Stamp Recipient - Food Stamp Case Number _____________________________

Household Income Information (complete only if family is not eligible for free school lunches or food stamps)

	List all income for all household members, and how often it is received (weekly, monthly, etc)
List names of everyone in your household	Income from work / before deductions	Income from work / job 2	Welfare, Child Support, alimony	Pensions, retirement, Social Security	Other Income

Name of Parent / Guardian____________________________________________________________

Address __________________________________________________________________________

City / State / Zip_____________________________________________ Phone__________________

I certify that the above named child is my dependant, and that the information contained on this form is true and correct: ___________________________________________ _________________

Signature date

Office use only:

Eligible for Scholarship ____ Yes ____ No Family Notified / Date ________________

Tsunami Official____________________________________

Signature __________________________________________ Date___________