Arts for All Scholarship Application 2021

I am the *

Applicant Parent Guardian Group Home

Applicant Information
Applicant Name

First Name Last Name
Date of Birth

Month Day Year
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
Group Home Information
Name of Group Home
Group Home Contact Person

First Name Last Name
Group Home Phone Number

Area Code Phone Number
Group Home Email
example@example.com
Parent/Guardian Information
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
What is your preferred form of communication?

phone text email
Emergency Contact

First Name Last Name
Emergency Contact Information

Area Code Phone Number
Demographic Information
What race does the applicant identify as?

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
What ethnicity does the applicant identify as?

Hispanic or Latino or Spanish Origin Not Hispanic or Latino or Spanish Origin
Financial Needs
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 have a Massachusetts-issued

EBT (Electronic Benefits Transfer) Card WIC (Women Infants and Children) Card ConnectorCare Health Plan Insurance Card
Massachusetts residents who are EBT, WIC, and ConnectorCare Health Plan Insurance cardholders are automatically qualified for partial or full scholarships for Follow Your Art Community Studios classes, workshops, vacation and summer camp programs. Tuition will vary and is based on availability.
Do you or your family qualify for food stamps?

yes no
Briefly describe any financial needs (if comfortable)
Social/Emotional Needs

(includes social/emotional, mental health, physical, behavioral, learning and cognitive/intellectual challenges)
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
Interests

Not sure? Go to fyamelrose.org and look at our offerings.
Which programs are your interested in?

Adult Programming
How did you find out about the Arts for All Scholarship Program?

Facebook Instagram Card to Culture Program Listing on mass.gov Follow Your Art Community Studios website Mailing Melrose Public Schools Eblast Word of mouth
Is there anything else you would like to share with us?
Questions?
email: artsforall@fyamelrose.org
phone: (781) 665 4140
Should be Empty:

Applicant Information

Group Home Information

Parent/Guardian Information

Demographic Information

Financial Needs

Social/Emotional Needs

Interests