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2. 

3. DRC LIFEGUARD CERTIFICATION COURSE SCHOLARSHIP APPLICATION

   *Please Note* In order to apply for the DRC Lifeguard Certification Course Scholarship, applicants must first either have an approved DRC Scholarship or submit and be approved. If you need to apply for a DRC scholarship follow this link: DRC Scholarship Application 

5. I have a current approved DRC scholarship (100% or 50%)*
   -- Select One --YesNo

7. Applications submitted for the Lifeguard Certification Course Scholarship are required to meet the criteria listed below and documentation must be submitted with application.  Once applications are received, applicants will be notified with in 10 business days if they have been awarded the scholarship.

9. Applicant must be a resident of USD 260*

   1. Yes
10. Proof of residency is required*

    1. Kansas Driver's License
    2. Current Utility Bill
11. Proof of dependency is required*

    1. 1040 Federal Taxes
    2. Medicare card listing dependents
13. Documents accepted for proof of income*

    Must supply one of the following

    1. Current Federal Income Taxes 1040
    2. Supplemental Security Income (SSI)
    3. Current Unemployment Forms

    1. USD 260 Child Enrollment Benefits
    2. Supplemental Security Disability Income (SSDI
17. Participant Information:
19. First Name*
20. Last Name*
22. Address1*
24. City*
25. State*
26. Zip*
28. Date of Birth*
    Date of Birth
29. Email Address*
30. Phone Number*
34. Emergency Contact Information
36. First Name*
37. Last Name*
39. Address1*
41. City*
42. State*
43. Zip*
45. Phone Number*
49. Why would you like to become a lifeguard?*
51. Why are you the ideal candidate for the Lifeguard Certification Course Scholarship?*
53. Which Lifeguard Certification Course will this scholarship be applied to?*
    -- Select One --Course 1: February 12-16, 2026Course 2: March 13-17, 2026Course 3: April 23-27, 2026
55. Prerequisites

    Upon receiving this scholarship, the participant still must complete the required pre-requisites listed below to continue with the Lifeguard Certification Course.  Upon successful completion of the prerequisites, and successful completion of the course and final, participants will receive a Lifeguard Certification that is valid for 2-years through the American Red Cross.

    1. Be at least 15 years old by the last day of the course .

    2. Complete the same swim-tread-swim sequence: Swim 150 yards, tread water for 2 minutes using only their legs, and swim 50 more yards. Swim must be performed using either freestyle or breaststroke.

    3.  Complete a retrieval exercise within 1 minute 40 seconds or less. This includes 20 yard swim, surface dive retrieve a 10 lb. brick from 9-12' depth, swim back 20 yards and exit without using a ladder or steps.

57. By typing your name below and submitting this application, you agree to the following:

    I certify that this information is accurate to the best of my knowledge. I agree that I must complete all prerequisites at the beginning of the class, to continue with the Lifeguard Certification Course.  I agree to work for Rock River Rapids and the Derby Recreation Commission for the summer season.

59. Signature (type) Name of Applicant*
60. Date*
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field