View Application in Spanish

APPLICATION

Please complete the below application. Incomplete forms will not be processed. Completed applications will be evaluated on a case by case basis.  While Keep Swimming Foundation strives to make as many grants as possible, submission of a completed application does not guarantee that your application will be selected for a grant. Before completing this form, please make sure you receive consent from the family, patient and any medical professionals you reference.

Section 1: Nominator's Information
Name of Nominator *
Name of Nominator
Phone Number of Nominator *
Phone Number of Nominator
Address of Nominator *
Address of Nominator
If you are a hospital staff member, please provide the hospital's address.
If you answer "No", please do not continue with this application until consent is granted. Keep Swimming Foundation is not responsible for any collected information submitted without consent.
Section 2: Family Information
If Keep Swimming Foundation advances the nominated family to Step 2, the family will be required to complete the remainder of the application process. Please provide the contact information of one family member who will oversee the application.
Name of Family Representative *
Name of Family Representative
Phone Number of Family Representative *
Phone Number of Family Representative
Section 3: Patient Information
Name of Patient *
Name of Patient
Date of Admission to Hospital *
Date of Admission to Hospital
Date of Discharge (Or Anticipated Date of Discharge) *
Date of Discharge (Or Anticipated Date of Discharge)
If the date of discharge is unknown, please provide an optimistic guess. (Focus on your family. We will focus on the formalities).
Section 4: Hospital Information
Hospital Address *
Hospital Address
Name of Hospital Physician or Nurse Familiar with Patient's Care *
Name of Hospital Physician or Nurse Familiar with Patient's Care
Phone Number of Physician or Nurse *
Phone Number of Physician or Nurse
This individual will be contacted, so please make sure they are notified in advance.
Section 5: Grant Request
$
What Expenses Will the Grant Aid the Patient's Family With? *
By clicking "submit" you certify that the information you submitted is truthful and that the patient consented to having their information shared with Keep Swimming Foundation, Inc.
Non-Discrimination Statement and Policy: Keep Swimming Foundation does not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. HIPAA Authorization Form Notice: You will be required to submit a HIPAA Authorization Form. Please consult with the medical team at your hospital to obtain this form. More information regarding this step will be sent to you via email upon submission of this application.