Scholarship Application Form

Parent Name 1(Required)

First Last

Parent Name 2

First Last

Are you a one parent or two parent household according to IRS?

One Parent

Two Parent

Student Name(Required)

First Last

Student's Grade Level (Rising)

What is Household Gross Income (as seen on line 9 of your IRS form 104d)(Required)

We must know the Total Income for all income earners in the household.

Please note if the parents file separate tax returns you must both provide income info

Number of children in family under the age of 18(Required)

Program Applied to:(Required)

Youth Jazz

MusicWorks!

Youth Orchestra

Summer Camps

Extenuating circumstances – Please Explain(Required)