Adaptive Assistance Request Form 2023

Adaptive Assistance Request Form

Arts for All at Follow Your Art Community Studios, 2023
Follow Your Art Community Studios provides adaptive services for you/the student(s) upon request.

Our Arts for All program makes every effort within its resources to work with each applicant’s needs to offer individualized adaptive assistance.

Arts for All can offer adaptive assistance for persons with disabilities (learning, physical), persons with mental health needs, and/or persons who require translation services. This can look like making appropriate curricular and/or space accommodations or modifications, or hiring an assistant to provide individualized aid, to name a few.

Filling out this form will help us better understand how to support you/the student(s) in accessing programs at Follow Your Art Community Studios should support be requested or needed.

After filling out this application, our Arts for All Coordinator will be in touch by phone with the applicant to discuss recommend programming and supports.
Applicant Information

Information of the person applying for tuition assistance.
Applicant Name*

First Name Last Name
Date of Birth*

MonthDay Year
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred mode of communication (check all that apply)

EmailPhone
Applicant Relationship to Student*

SelfParentLegal guardianOther relativeGroup home contactOther
Student Information

Information on the student(s) hoping to participate in FYACS programming.
What program session are you applying for adaptive services?*

Winter 1February Vacation WeekWinter 2SpringApril Vacation WeekSummerFall 1Fall 2Workshop
How many people are you requesting adaptive services for during this session? *
Name of student 1 *
Age of student 1*
Interests of student 1 (check all that apply)*

CeramicsDrawingPaintingDigital ArtWritingTheatre / PerformanceArt ClubSculpture
Name of student 2*
Age of student 2*
Interests of student 2 (check all that apply)*

CeramicsDrawingPaintingDigital ArtWritingTheatre / PerformanceArt ClubSculpture
Name of student 3*
Age of student 3*
Interests of student 3 (check all that apply)*

CeramicsDrawingPaintingDigital ArtWritingTheatre / PerformanceArt ClubSculpture
Name of student 4*
Age of student 4*
Interests of student 4 (check all that apply)*

CeramicsDrawingPaintingDigital ArtWritingTheatre / PerformanceArt ClubSculpture
In order to help us identify what kinds of support we can put in place, please describe the needs, diagnoses, and/or types of adaptive assistance that would best serve the student(s). *
Our Arts for All Coordinator will follow up with you to discuss how to best support the student in attending programs at FYACS.
Are you also looking for financial assistance at this time?

YesNo
Financial Need
Please share the following information to help assess your level of need.

Follow Your Art Community Studios is pleased to be participating in the Massachusetts Cultural Council Card to Culture program, by extending discounts to EBT, WIC, and ConnectorCare health plan insurance cardholders.

Tuition assistance is also be available to those who do not carry EBT, WIC, or ConnectorCare health plan insurance cards.
Check if you have one or more of the following Massachusetts-issued Cards:*

EBT (Electronic Benefits Transfer) CardWIC (Women Infants and Children) CardConnectorCare Health Plan Insurance Card (AllWays Health Partners, Fallon Health, Health New England, Tufts Health Plan, and WellSense Health Plan, formerly BMC HealthNet Plan)I do not have any of the above Massachusetts-issued cards
Average yearly gross income (optional)
How much tuition assistance / what type of assistance are you looking for?*

1-10% assistance11-25% assistance26-50% assistance51-75% assistance76-85% assistancePayment PlansI'm not sureOther
Please describe your financial needs (if comfortable)
The amount of tuition assistance we are able to offer varies depending on donations, grants, and the number of requests we receive. Every session, we make every effort within our resources to work with each applicant’s needs.
How did you find out about the Arts for All Program?

FacebookInstagramCard to Culture Program Listing on mass.govFollow Your Art Community Studios websitePostcardMelrose Public Schools Virtual BackpackWord of mouthOther
Is there anything else you would like to share with us?
Questions?

Email: artsforall@fyamelrose.org

Phone: (781) 665 4140

Arts for All Office Hours: Tuesdays & Fridays 9-12PM
Should be Empty:

Adaptive Assistance Request Form

Applicant Information

Student Information

Financial Need