SWIMMING LESSON & BICYCLE HELMET ELIGIBILITY DETERMINATION

Financial assistance is based on the household size and income. 

 

FAMILY INFORMATION

 

Parent/Guardian Name  ________________________________________________

 

Address_____________________________________________________________

 

City/Zip Code ________________________________________________________

 

Home Phone #  ____________________Work Phone # _______________________

 

Gross Monthly Household Income_________________________________________

Number of People in the Household ___________      __________________________

Emergency Contact & Phone    ___________________________________________________

 

CHILD INFORMATION (please attach additional sheets if necessary)

 

Name __________________________________________ Age____ Sex ____

Optional) Ethnicity                                   ___________________

 

CHILD INFORMATION (please attach additional sheets if necessary)

 

Name __________________________________________ Age____ Sex ____

Optional) Ethnicity                                   ___________________

 

CHILD INFORMATION (please attach additional sheets if necessary)

 

Name __________________________________________ Age____ Sex ____

(Optional) Ethnicity                                  ___________________

 

As the legal guardian of the above children, I agree to hold all members of the Volusia/Flagler SAFE KIDS Coalition and their respective officers and agents free and harmless from any claim or expense that may arise due to participation in this program.  I am aware that the completed information is shared only with the Volusia/Flagler SAFE KIDS Coalition and their respective officers and partners.

 

In case of an accident the staff is authorized to take whatever emergency medical measures are necessary for the protection of my child, including the transportation to a hospital or clinic.  I understand that all efforts will be made to contact me or the emergency contact before any action is taken.

 

Insurance__________________________ Policy #________________

 

I certify that the information on this application is correct.

 

Signature _______________________Date __________

 

PLEASE CONTACT Volusia/Flagler SAFE KIDS Coalition to find out whether your child is eligible for this service/program and for more information:

 

 

Volusia/Flagler SAFE KIDS Coalition

C/O Healthy Communities

655 N. Clyde Morris Blvd., Suite A, Daytona Beach, FL 32114

(386) 323-0000/ FAX (386) 323-0008