2. Swimmer's Last Name*
3. Swimmer's First Name*
5. Swimmer's Middle Initial
6. Parent/Guardian's Full Name*
8. Street Address*
9. Apt/Unit #
11. City*
12. State*
13. Zipcode*
15. Primary Phone #:*
16. Secondary Phone #:
18. PARKS DIRECT Household #:
19. E-mail Address:*

21. The following section is to be completed using the IRS Return Transcript. Please attach IRS Return Transcript to application.

23. IRS Return Transcript*
25. Tax Year:*
26. Adjusted Gross Income:*
27. Number of Family Members Listed on Transcript:*
29. Swimmer Participation*

    Has your swimmer participated on the PGPR Sharks team in the past?

    1. Yes
    2. No
30. PGPR Sharks Team Participation

    If so, how many years of participation?

    1. Under 1 year
    2. 1 year
    3. 2 years
    4. 3 years
    5. 4 years
    6. 5 years and up
32. Ethnicity*

    This scholarship is for African American and Hispanic or Latino swimmers.  Would you describe your swimmer in either of these categories?

    1. African American
    2. Hispanic
    3. Latino
    4. Other
33. Seasons*

    Which swim seasons are you interested in applying for the Aquatics For All scholarship?

    1. 2022-2023 School Year
    2. 2023 Summer
    3. Both
35. Agreement*

    If selected each scholarship recipient is required to agree to each of the below (either signature or check box):

    1. Competing on the PGPR swim team for the full season
    2. Make scheduled payments on time based on provided schedule
    3. Exhibit good sportsmanship throughout all PGPR activities
    4. Agree to participate in promotional material which may include photography
37. Certification:*

    I certify that all of the above information is true and correct. I understand that Commission officials may verify the information on the application, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state laws. I understand that I am responsible for all remaining charges that award may not cover and will be withdrawn from any program registrations without notice if I failed to pay my full balance after the deadline.

    1. I understand
39. Electronic Signature*
40. Date:*
    Date:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field