Financial Assistance Form for In-Theater Programs

Financial Assistance Form for In-Theater Programs
Date*

MonthDayYear
Date
Section 1:
Name of Dependent Child that would benefit from this assistance: *
The program(s) for which you are requesting assistance:*

Summer CampsVacation CampsPlay Me a StoryClassesOther
Applicant’s Information:
Name: *

First NameLast Name
Relationship to participant: *
Primary Phone Number: *
Please enter a valid phone number.Format: (000) 000-0000.
Email: *
example@example.com
Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant’s Employer:*
Supervisor: *
Employer’s Phone: *
Please enter a valid phone number.Format: (000) 000-0000.
Are there any additional adults contributing to the financial support of the child?*

YesNo
Additional contributing adult information will be:

Included belowSent separately from this form (Please email education@portlandstage.org)
Name of additional contributing adult:

First NameLast Name
Primary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Supervisor:
Employer’s Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Additional Dependents/Children (if applicable):
1. Name, DOB, Age, Relation
2. Name, DOB, Age, Relation
3. Name, DOB, Age, Relation
4. Name, DOB, Age, Relation
5. Name, DOB, Age, Relation
Section 2:
If you are on Public assistance please check the appropriate item:*

Not applicableAFDCEAEDCVeteran’s BenefitsFood StampsOther
Please submit a copy of your card or other verification:

Cancelof
Section 3:

Monthly Income (designate type of income and amount received each month): **Please attach documentation from any source of income you are receiving. All contributing guardians or adult household members who are working are asked to submit a copy of check stubs from the last three weeks.
Wages (before taxes, etc. are taken out):
Attach file here:

Cancelof
SSI Amount:
Attach file here:

Cancelof
AFDC Amount:
Attach file here:

Cancelof
Unemployment Amount:
Attach file here:

Cancelof
Disability Amount:
Attach file here:

Cancelof
Child Support Income:
Attach file here:

Cancelof
Total Monthly Income:*
Any additional documents:

Cancelof
Any additional documents:

Cancelof
Section 4:
Total current value of any accounts (investment, checking, and retirement): *
Section 5:
What do you feel you could contribute, if any, to the cost of the program? *
Section 6:
Have you received financial assistance in the past from Portland Stage Company?

YesNo
If yes, for what program, when and how much?
Section 7:

The statements and responses I have given are true and correct.
Signature
Please return this form and necessary verification to:

Michael Thomas, Education DirectorJulianne Shea, Education Administrator Portland Stage Company P.O. Box 1458Portland, ME 04104
Should be Empty:

Financial Assistance Form for In-Theater Programs

Section 1:

Applicant’s Information:

Additional Dependents/Children (if applicable):

Section 2:

Section 3:

Section 4:

Section 5:

Section 6:

Section 7:

Please return this form and necessary verification to: