Financial Aid Form

Applications are accepted on a first-come, first-served basis. Please complete a separate application for each student. Notification will be made by email. Please refrain from calling the Arts Center to inquire about scholarships or financial aid decisions. Scholarship recipients will be notified on a rolling basis.

"*" indicates required fields

STUDENT INFORMATION

Student First Name*

Student Last Name*

Student birthdate*

MM slash DD slash YYYY

Student Address*

Street Address City State / Province / Region ZIP / Postal Code

Student School*

Student Grade*

What do you like to do?*

Please tell us a little about yourself!*

What are some of the things you are interested in?*

List three words that describe your personality:*

Discipline (Select One)*

Dance

Theater

Visual Arts (Painting, Watercolor, Oil)

Ceramics

Fencing

Fitness

Language

Cooking (Culinary)

Summer Camps

Violin/Viola/Cello/Bass - Private Music Instruction

Piano - Private Music Instruction

Saxophone/Clarinet - Private Music Instruction

Percussion - Private Music Instruction

Flute - Private Music Instruction

Voice - Private Music Instruction

Guitar - Private Music Instruction

List the class(es) you would like to attend September through August.*

PARENT / GUARDIAN INFORMATION

First Name of Parent / Guardian*

Last Name of Parent / Guardian*

Birth Date of Parent / Guardian*

MM slash DD slash YYYY

Parent / Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Select County*

Phone*

Email*

Does the student live with you? Elsewhere?*

Total Annual Household Income:*

Under $50,000

$50,000 - $100,000

$100,000 - $150,000

Over $150,000

Employer*

Length of Employment*

Title*

Will you be willing to provide a pay stub or W2 as proof of income if selected?*

Yes

Total number of people in household*

PAST SCHOLARSHIP / FINANCIAL AID INFORMATION

Has the student taken any classes at 171 before? If yes, what was the most recent? If not, was there a reason that had prevented it?*

Has the student applied for a 171 scholarship / financial aid before?*

Has the student received a 171 scholarship / financial aid before?*

How much was awarded?*

What class(es) did they attended?*

Did they attend class regularly?*

If a full award is not received, what portion of the tuition would you be able to pay each month?*

Are there any circumstances you feel we should know of when considering your application? Please provide information:*

BY APPLYING FOR SCHOLARSHIP / FINANCIAL AID FUNDING, I AGREE TO THE FOLLOWING TERMS:

• To attend class regularly.

• To help create a positive atmosphere for all to learn.

• To complete a class evaluation at the completion of the class.

• To write a thank you note or draw a picture to the scholarship funder at the end of class.

• To participate in group exhibitions, concerts, or recitals that may be part of the lesson plan for the class I take.

I have completed this form accurately, in good faith, and to the best of my knowledge.*

Digital Signature of Guardian

Name

This field is for validation purposes and should be left unchanged.

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