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MoCo Arts Scholarship Application Form

In addition to this information a copy of the 2010 IRS form 1040 listing the applicant as either taxpayer or dependent needs to be submitted. Please mail a copy of this form to ‘Scholarship Committee, MoCo Arts, 76 Railroad St, Keene NH 03431

Select Session Applying for

First Name

Last Name

Date of Birth
mm/dd/yyyy

Parent/Guardian Name
(if under 18)

Address 1

Address 2

City

State

Zip Code

Home Telephone

Cell Phone

Work Phone

Valid E-Mail Address

# of Members in Household

Financial Assistance is for ONE class only (Maximum of 60% of class cost)
*Please register with a deposit of $25.00, pending scholarship notification to secure a place in the class. This deposit will be applied to your class cost.

Class Name, Day, & Time you wish to Register for

How much tuition are you requesting?

Are there any special circumstances that the Scholarship Committee should know about?

Please supply one person we can contact for a recommendation

Name

Telephone Number

How does this person know the applicant?

Please write a brief letter about why you want to participate in classes at MoCo Arts.

I want to attend classes at MoCo Arts because...

Do we have permission to quote you, using first name only? Yes No

By checking this box I understand this application is not complete and will not be reviewed or considered until a copy of the 2010 IRS form 1040 listing the applicant as either taxpayer or dependent needs to be submitted. I will mail a copy of this form to: Scholarship Committee, MoCo Arts, 76 Railroad St, Keene NH 03431

A third part of the application will be mailed to you upon completion prior to the end of the session you have attended. All applicants who receive tuition assistance will need to express in writing what the class has meant to them.

By submitting this form, you have verified that all above information is correct.

Please make a selection.

All tuition assistance is awarded without regard to sex, race, religion, national origin or sexual preference. All information is confidential.

MoCo Arts Scholarship Application Form In addition to this information a copy of the 2010 IRS form 1040 listing the applicant as either taxpayer or dependent needs to be submitted. Please mail a copy of this form to ‘Scholarship Committee, MoCo Arts, 76 Railroad St, Keene NH 03431
Select Session Applying for
First Name
Last Name
Date of Birth	mm/dd/yyyy
Parent/Guardian Name (if under 18)
Address 1
Address 2
City
State
Zip Code
Home Telephone
Cell Phone
Work Phone
Valid E-Mail Address
# of Members in Household
Financial Assistance is for ONE class only (Maximum of 60% of class cost) *Please register with a deposit of $25.00, pending scholarship notification to secure a place in the class. This deposit will be applied to your class cost.
Class Name, Day, & Time you wish to Register for
How much tuition are you requesting?
Are there any special circumstances that the Scholarship Committee should know about?
Please supply one person we can contact for a recommendation
Name
Telephone Number
How does this person know the applicant?
Please write a brief letter about why you want to participate in classes at MoCo Arts.
I want to attend classes at MoCo Arts because...

Do we have permission to quote you, using first name only? Yes No
By checking this box I understand this application is not complete and will not be reviewed or considered until a copy of the 2010 IRS form 1040 listing the applicant as either taxpayer or dependent needs to be submitted. I will mail a copy of this form to: Scholarship Committee, MoCo Arts, 76 Railroad St, Keene NH 03431
A third part of the application will be mailed to you upon completion prior to the end of the session you have attended. All applicants who receive tuition assistance will need to express in writing what the class has meant to them.

By submitting this form, you have verified that all above information is correct. Please make a selection.

*All tuition assistance is awarded without regard to sex, race, religion, national origin or sexual preference. All information is confidential.*