Financial Need-based Scholarship Form

Scholarship opportunities for persons seeking to engage their creativity.

Student Information
Applicant Name*
First Last
Gender*
Age*
Please enter a number greater than or equal to 7.
Birth Date*
MM slash DD slash YYYY
Ethnicity (optional)
- White
- Black
- Hispanic
- Asian/Pacific Islander
- American Indian/Alaskan Native
- Other
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Have you previously participated in an experience at GoggleWorks Center for the Arts?*
If applicant is under 18, please provide the following:
Parent/Guardian Name*
First Last
Current School*
Current Grade*
Experience Selection:
Indicate the experience (including date and time) you are interested in below. Please note that scholarship seats are offered on a first-come, first-served basis and depend on the current availability. Age restrictions may be applicable. Any exceptions must be pre-approved by the Programs Department.
First Choice*
Start Date*
MM slash DD slash YYYY
Second Choice
Start Date
MM slash DD slash YYYY
Third Choice
Start Date
MM slash DD slash YYYY
Financial Documentation:
The following information is required to determine eligibility for scholarship acceptance. All information will be kept confidential.
Please attach a complete copy of your most recent Form 1040 income tax return.*
Max. file size: 128 MB.
Number of individuals (adults and children) supported by this income*
If applicant is under 18, please provide one of the following:
Copy of students free and reduced lunch program ID card OR medicaid card*
Max. file size: 128 MB.
e-signature
The information supplied is true and accurate to the best of my knowledge. I understand that any false information will result in cancellation of this application and any scholarship granted.*
Date*
MM slash DD slash YYYY

Financial Need-based Scholarship Form

Student Information

If applicant is under 18, please provide the following:

Experience Selection:

Financial Documentation:

If applicant is under 18, please provide one of the following:

e-signature

Albert and Eunice Boscov Film Theatre

Exhibitions

The New Store