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

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 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 email

Emergency Contact

First Name Last Name

Emergency Contact Information

Area Code Phone Number

How does the applicant identify themselves?

American Indian or Alaska Native Black or African American Native Hawaiian or other Pacific Islander White (Hispanic or Latinx) White (not Hispanic or Latinx)

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)

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

Which programs are your interested in?

Summer Showstoppers Adult Programming

If you already know, tell us the specific class you are interested in.

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 Word of mouth

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

Questions?
email: artsforall@fyamelrose.org
phone: (781) 665 4140,

Applicant Information

Group Home Information

Parent/Guardian Information

Emergency Contact

Demographic Information

Financial Needs

Social/Emotional Needs

Interests