General Information

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1. Full name (Required.)

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2. Date of birth (Required.)

Date

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4. Phone number (Required.)

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5. Broward County resident (Required.)

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6. Mailing address (Required.)

Professional Information

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7. Please select your employment status as a swim instructor: (Required.)

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8. For which organization or company did you most recently teach swimming lessons? (Required.)

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9. Approximately how many students do you teach annually? (Required.)

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10. How many years of experience do you have as a swimming or water safety instructor? (Required.)

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11. Do you currently provide instruction to children or individuals with special needs? (Required.)

Documentation

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12. Upload your current CPR certificate along with a swimming or water safety instructor certification from one of the following organizations: American Red Cross, YMCA, SwimAmerica, or Infant Swimming Resource (ISR). The certificates you upload must clearly display the certifying organization, certificate number, and expiration date. (Required.)

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13. By submitting this application for the Swim Instructors Adaptive Aquatics Certification Scholarship, you agree to receive email, phone, and text message communications from the Florida Department of Health in Broward County. (Required.)

You will receive an email within 10 business days after submitting your application, notifying you of its approval status. We will contact you via the email you provide.
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