Adaptive Assistance Request Form

Adaptive Assistance Request Form

Arts for All at Follow Your Art Community Studios
You belong at The Big Yellow House and we will work with you to be here.

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

After filling out this application, our Arts for All Coordinator will be in touch to discuss programming and support options.
Contact Information

This person will be contacted regarding this application.
Applicant Name*

First NameLast Name
Pronouns (optional)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred mode of communication (check all that apply)*

EmailPhone
Student Information

Information on the student hoping to participate in FYACS programming.
Applicant Relationship to Student*

SelfParentFoster parentLegal guardianOther relativeGroup home contactSocial WorkerOther
What program session are you applying for adaptive services?*

Winter 1February Vacation WeekWinter 2SpringApril Vacation WeekFall 1Fall 2SummerWorkshop at FYACS
What class is the student interested in taking (theater, ceramics, painting, etc.)? See fyamelrose.org/programs/ for specific listings.
See www.fyamelrose.org/programs/ for more information
Name of student *
If applying for multiple students, please fill out new form for each student
Pronouns of student (optional)
Age of student (if an adult, can write "adult")*
Date of birth

MonthDayYear
Date
In order to help us identify what kinds of support we can put into place, please describe the students diagnoses or other important information.*
Our Arts for All Coordinator will follow up with you to discuss how to best support the student in attending programs at FYACS.
Please describe the types of adaptive assistance that would best serve the student.
What systems or procedures has helped the student in the past, or what might help them better succeed at FYA? For example: Is there specific language that helps in communication? Does the student use an assistive device? Would the student benefit from an interpreter? Are there physical adaptations to our space that would help? If the student is receiving adaptive services elsewhere, what are they?*
Our Arts for All Coordinator will follow up with you to discuss how to best support the student in attending programs at FYACS.
Would the student benefit from having a 1:1 aide to participate in a class? Please explain.*
Our Arts for All Coordinator will follow up with you to discuss how to best support the student in attending programs at FYACS.
If there is any other information that would help us support the student, please include it here.
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
Our creative programming is for everyone!

Follow Your Art offers:
- Tuition reductions up to 80%
- EBT and WIC card holders are eligible for a minimum of 50% off class tuition,
- but you do not need these cards to qualify for aid!
Number of Scholarships:
- Individuals are eligible for up to 4 scholarships per calendar year.
- Families are eligible for up to 6 total scholarships per calendar year.
- Summer Scholarships are currently limited to 1 week per student.
You belong at The Big Yellow House and we will work with you to be here.

Please share the following information to help assess your level of need.
Check if you have one or more of the following Massachusetts-issued Cards:*

EBT (Electronic Benefits Transfer) CardWIC (Women Infants and Children) CardI do not have any of the above Massachusetts-issued cards
How large in your household?*
Average yearly total household income (optional)
Based on the cost of your chosen program (see fyamelrose.org/programs for all program costs), what type of assistance do you need? (check all that apply)*

1-10% assistance off program costs11-25% assistance off program costs26-50% assistance off program costs51-75% assistance off program costs76-80% assistance off program costsPayment PlanI'm not sureOther (describe below)
Please describe your financial situation and any specific circumstances that would help us better understand your needs. If you are an EBT or WIC cardholder and require additional support beyond the standard 50% aid, please include additional information so we can see how we might support you further.
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. Applications are processed in the order in which they are received.
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
Should be Empty:

Adaptive Assistance Request Form

Contact Information

Student Information

Please describe the types of adaptive assistance that would best serve the student.

Financial Need