Instrument Scholarship Request Form
This form should be completed by the instrumental music teacher, not a parent or student.
Student Information
Student Name
*
First Name
Last Name
Age
*
Grade
*
Instrument Choice
First Choice
*
Second Choice
*
School and Nominee Information
Name of School
*
Band/ Orchestra Director's Name
*
First Name
Last Name
Band/ Orchestra Director's Email
*
example@example.com
Principal's Name
*
First Name
Last Name
School Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
The student above has been recommended to receive an instrument from WVYMF. This student has met all of the following prerequisites for qualifying for the program:
Select all that apply
*
The student is officially enrolled at your school
The student participates or desires to participate in the instrument program at your school.
The student has demonstrated a good work ethic in the classroom.
The student is in good academic standing
The student has demonstrated an aptitude in music.
The student is a responsible young person who will show respect for the instrument.
The student's parents or guardians have been unable to secure an instrument through conventional means
Acknowledgement
By signing below you acknowledge that you understand this request will be fulfilled based on the availability of the instrument requested. The instrument may be used by the above student for as long as that student participates in the school instrumental music program. If an instrument is granted on scholarship to this student, the school agrees to monitor its use and return the instrument to Chirp should the above student no longer need the instrument.
Principal's Signature
*
Date
*
-
Month
-
Day
Year
Date
Band/Orchestra Director’s Signature
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
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Should be Empty: