Participation Form | Aqua Boss LLC

Date

Month

Day

Year

Name

Birthday

Month

Day

Year

Male

Female

Multi-line address

Country/Region

Address

City

Zip / Postal code

Ethnicity:

Does anyone in your household receive any of the following benefits:

CalFresh (Food Stamps)

Medi-Cal

Cash Assistance

I receive none of the above benefits.

Household Income (MFI):

Extremely Low (30%)

Low Income (50%)

Moderate Income (51-80%)

Not low/Moderate Income (+81%)

Please list any medical or health reason which would affect, limit or prohibit participation in the County’s Aquatic Program.

Kennedy Community Pool Participation Form