ART Station, Inc.
Summer Arts Camp/Performance Program Scholarship Application Form
Application Deadline: Must be received by ART Station by Friday, May 20, 2016 at 5:00 p.m.
Note: Scholarships are available only to students attending multiple weeks (2 or more) full-day sessions of Summer Arts Camp or a Performance Company. Please submit a separate form for each child. Scholarship award depends on number of applicants and funds available. In most cases scholarships are equal to no more than $50 per week for multiple week campers (two week minimum), not including registration fees and membership fees.
Name of Student: ______
Age of Student: ______
Ethnic Group of Student: Black _____ White _____ Am. Indian _____ Hispanic _____ Other _____
Full Name of Legal Parent or Guardian: ______
Address: ______
City: ______State: ______Zip: ______
Phone (cell) ______(home) ______
(work) ______(other)______
Number of people in the family household: _____ (Note: If you are using a 1040 form to verify your income level, this number must equal the number listed on the IRS 1040 submitted for proof of income.)
Name of DFACS Case Worker:______
Phone Number of DFACS Case Worker: ______
Head of Household Name: ______
Head of Household: Male ______Female ______
In order to receive a scholarship for Summer Arts Camp or Performance Company, the family income must be verified as less than the following. Please circle the one that applies to you.
2 persons $46,000
3 persons $51,750
4 persons $57,450
5 persons $62,050
6 persons $66,650
7 persons $71,250
8 persons $75,850
Please list names and ages of all individuals living in the household below. (Please continue on other side if necessary.)
Method of Income Verification:
There are three acceptable methods of income verification. 1) Copy of Medicaid Card with name of the child and date equal to the date of the application date of this form. 2) PeachState Insurance Card with name of the child and date equal to the date of the application date of this form. 3) Copy of the most recent Federal Income Tax Form 1040 (front and back with signature and name of child listed as dependent.) Please note: One of these forms of verification must be included with the application or the application will not be processed.
Which method of income verification are you using? Medicaid Card _____
PeachState Card _____ Copy of Federal Income Tax Form 1040 ____
I hereby certify that the information provided on this form is true, accurate, and verifiable to the best of my knowledge. Any misrepresentation or distortion of these facts may result in the denial of scholarships.
Signature of Parent or Guardian: ______
Date: ______
Mail this form along with the Summer Arts Camp Registration form and appropriate fees (Membership $35 and $75 deposit) to:
ART Station, P.O. Box 1998, Stone Mountain, GA 30086.