Gateway Music Outreach Adopt-A-Musician Scholarship Application
I. PARENT SECTION
Student Name
First Name
Last Name
Parent or Legal Guardian Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Legal Guardian
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/ Legal Guardian Email
example@example.com
What is the best time to call?
Emergency Contact Name & Contact Number
Student Date of Birth
(Date/ Month/ Year)
Student Age
Student Grade
Name of School & School District
Student Ethnicity
Black/ African American
Native American
Hispanic/ Latin American
Multi-Ethnic
Asian American
Native Hawaiian/ Pacific Islander
White/Caucasian American
Other
How would you describe your student's academic performance?
Excellent-"A" Average
Good-'B" Average
Fair-"C" Average
Needs Improvement
Does your student have any physical or developmental disabilities which impact concentration or learning?
Yes
No
If you answered yes to previous question please, explain.
Has your student taken private music lessons before?
Yes
No
If so, please communicate the instrument and the number of years your student has been playing?
Does your student’s school district have an orchestra program?
Yes
No
If so, is your student currently participating.
Yes
No
If not, please explain why.
Does your child currently quality for free or reduced lunch?
Yes
No
Total Household Size
Total Household Income
$9,999 or below
$10,000-$19,999
$20,000-$29,000
$30,000-$49,999
$50,000-$69,999
$70,000-$89,999
$90,000 or above
II. STUDENT SECTION
What instrument are you interested in playing?
violin
viola
cello
bass
piano
other
If you answered other, explain which instrument you are interested in playing.
What are three things you would like to gain from this experience?
How will this scholarship benefit you in the future?
Parent/ Legal Guardian Signature
Submit
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