SCHOLARSHIP APPLICATION

First Name*

Last Name*

Company

Address*

City*

State*

Postal Code*

Country*

Email*

Day Phone*

Evening Phone

Input Birthdate of Individual Applying: Month Day, Year (ex. April 4, 1994)

Please check the box that applies to you.

		Military Personnel (Active Duty)
		Military Veteran (Honorably Separated)
		Civilian

This is not used in eligibility, strictly for tracking individuals served through the program. Please indicate how you identify as far as your ethnicity? (Ex. African-America, White, Latina/Latino, Black, Caucasian, Japanese, Korean, Asian, etc. - We realize some of these are redundant, but want to know your preferred term which is why there are no checkboxes.)

		Yes
		No

		Under $15,000
		$15,001 - $25,000
		$25,001 - $40,000
		$40,000 and up

Why do you want to participate in this program?

		Yes
		No

Please check the SCUBA Certifications that you currently hold. Before becoming a dive volunteer, your certification cards will need to be confirmed.

		Open Water SCUBA Diver
		Advanced Open Water SCUBA Diver
		Rescue Diver
		Buddy Disability Trained Diver
		Emergency First Responder

Please indicate which courses/programs you are looking to participate in/ scholarship value you are looking for.

		Open Water SCUBA Diver/ $800
		Advanced Open Water SCUBA Diver/ $700
		Rescue Diver/ $600
		Buddy Disability Trained Diver/ $750
		Emergency First Responder/ $500
		Kids SCUBA Camp/ $2,270
		Diving Therapy Program/ $12,000

Click to upload a file

Where would you prefer to complete your training? (County, State)

If a scholarship is approved, any training provider and program MUST be approved by AQUANAUTS ADAPTIVE AQUATICS. If you have a preferred provider, please list the name and contact information here. We will attempt to accommodate your request, however, they must meet our stringent training requirements.

In applying for a scholarship through AQUANAUTS ADAPTIVE AQUATICS, I understand that I am giving AQUANAUTS the authorization to verify my personal and financial information. I further understand that if I am granted a scholarship through AQUANAUTS, it will be paid directly to the training provider. I understand that my application serves as approval for my essay and/or image to be used in soliciting donations for Adaptive SCUBA Programs.

Also, if granted a full or partial scholarship for Buddy Disability Training or HSA Instructor Training, in the first year I am required to participate in 6 AQUANAUTS non-profit activities once training has been completed or I will be retroactively responsible for the full cost of my training.

By submitting this application, I am affirming that I understand and agree to all terms herein.

I have read and accept these terms and conditions.

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.

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SCHOLARSHIP APPLICATION

Is scholarship for a child age 10-17? If so, provide name of child:

What is your ethnicity?

Are you currently employed?

Employer Name

Employer Phone

Please check appropriate annual household income:

Have you been diagnosed with a disability?

If yes, please describe.

Upload Image of You (Optional)

Please upload essay (100-300 words) Why is SCUBA important to me?

Terms and Conditions

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