Arts for All Scholarship Application 2021

Applicant Name

First Name Last Name

Date of Birth

Date

Applicant Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Applicant Email

example@example.com

Applicant Phone Number

Area Code Phone Number

Parent/Guardian Name

First Name Last Name

Relationship to Applicant

Address

Street Address/Group Home Name

Street Address Line 2

City State

Zip Code

Parent/Caregiver Phone Number

Area Code Phone Number

Parent/Caregiver Email

example@example.com

How many members of your family would like to participate in FYACS programming?

*if a member of a group home add their name here

Name

Age

Name

Age

Name

Age

Name

Age

Best way to contact you

phone text email

Were you referred to us? *

yes no

Who referred you?

What are your needs or the needs of your family? *

financial social/emotional * both

*includes social/emotional, behavioral, mental health, cognitive/intellectual, learning and physical challenges

Does your family qualify for free lunch?

yes no N/A

Do you or your family qualify for food stamps?

yes no

Briefly describe any financial needs (if comfortable)

Briefly explain any social/emotional needs of you or your family as well as indicate if there are any diagnosed disabilities.

Do any of the members of your family have a school plan? (check all that apply)

IEP 504 N/A

Is there anything else you would like to share with us?

Please contact artsforall@fyamelrose.org if you have any questions. Thank you!

Applicant Information

Parent/Guardian Information

Referral Information

Financial Needs

Social/Emotional Needs