Section 1 of 1 in this document

Application for Reduced Fee for Aquatics Season Pool Pass

Home or Cell Phone

How many employers do you currently have?

Employer 1

Employer 1 Phone Number

Employer 2

Employer 2 Phone Number

Extenuating Circumstances?

Unemployment

Extensive Hospital Bills

Youth 1

Name *

Age *

Youth 2 (if applicable)

Name

Age

Youth 3 (if applicable)

Name

Age

Youth 4 (if applicable)

Name

Age

Youth 5 (if applicable)

Name

Age

Applicant (Parent/Guardian) Current Monthly Income

Applicant’s Current Annual Gross Income as reported on income tax return form

Please Note: any other earned or unearned income such as child support, alimony, reserve pay, retirement, food stamps, Public Aid, AFDC payments, etc. (attach Public Aid form)

Other Income 1

Source

Amount

Other Income 2

Source

Amount

Number of individuals residing at above address:

Adults *

Children *

*Submit with your application Proof of Residency and Proof of Income

Upload File(s)

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I certify that all of the above information is true and correct and that all income is reported. Bloomington Parks and Recreation Department staff may verify the information.

Application for Reduced Fee for Aquatics Season Pool Pass

Parent/Guardian Name

Full Address

How many employers do you currently have?

Extenuating Circumstances?

Youth 1

Youth 2 (if applicable)

Youth 3 (if applicable)

Youth 4 (if applicable)

Youth 5 (if applicable)

Applicant (Parent/Guardian) Current Monthly Income

Applicant’s Current Annual Gross Income as reported on income tax return form

Other Income 1

Other Income 2

Number of individuals residing at above address:

Upload File(s)

Sign Here