DOH-Broward Swimming Lesson Voucher Child Information: Question Title * 1. First Name of Child (Required.) Question Title * 2. Last Name of Child (Required.) Question Title * 3. Child's Date of Birth (Required.) Please enter child's date of birth below Date Question Title * 4. Does the child have Medicaid? (Required.) Yes No Parent/Guardian Information: Question Title * 5. First Name of Parent (Required.) Question Title * 6. Last Name of Parent (Required.) Question Title * 7. Parent Email Address (Required.) Question Title * 8. Phone (Required.) Question Title * 9. Street Address (Required.) Question Title * 10. Apartment # Question Title * 11. City (Required.) Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach Hillsborough Beach Hollywood Lauderdale by the Sea Lauderdale Lakes Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac West Park Weston Wilton Manors Question Title * 12. Zip Code (Required.) 33004 33008 33009 33019 33020 33021 33022 33023 33024 33025 33026 33027 33028 33029 33060 33062 33063 33064 33065 33066 33067 33068 33069 33071 33073 33076 33082 33097 33301 33302 33304 33305 33306 33307 33308 33309 33310 33311 33312 33313 33314 33315 33316 33317 33319 33321 33322 33323 33324 33325 33326 33327 33328 33329 33330 33331 33332 33334 33336 33340 33351 33388 33394 33442 33441 Done