Individuals Sign Up Here

"*" indicates required fields

I am applying for:*

What type of membership are you applying for?*

Which swim lesson are you applying for?

Private or group lessons, lesson level, general timing for lessons.

Applicant Information:

Primary adult / guardian name*

Date of birth:*

Mailing address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Status:*

Secondary adult / spouse name

Primary adult / guardian name

Date of birth:

Mailing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Status:

Dependents

Dependents under 24 years old living in the household

Name

Date of birth

Name

Date of birth:

Name

Date of birth:

Name

Date of birth:

Finances & Circumstances

If you are applying for a family membership or swim lessons is your annual gross household income from all adults based upon line 8b of IRS Form 1040 less than $70,000? OR If you are applying for an individual membership is your annual gross household income from all adults based upon line 8b of IRS Form 1040 less than $30,000?

Do you meet our gross income criteria?*

Yes

Are you a year-round resident of Routt or Moffat County? Proof is required to be accepted.*

Yes

Are there any circumstances we should know about to assist us in our decision making process?*

Consent*

By ticking I agree that:

I certify that the above information is true and complete to the best of my knowledge. I agree, if requested, to provide documentation to support the above statements. I understand that assistance is based upon need, and if I falsify any of the above information, I will not be eligible for assistance. I will, if awarded scholarship, agree to the Old Town Hot Springs membership agreement, Code of Conduct, and all applicable organizational policies.

Please allow up to 4 weeks for a decision. Awards are either 4 months of membership or one swim lesson session (children only).

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Individuals Sign Up Here

Applicant Information:

Secondary adult / spouse name

Dependents

Finances & Circumstances

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