Instruments from the Attic
Student's Name _________________________________________
Home Phone ___________________ Date of Birth ______________________
Parent/Guardian Name _________________________________________
Instrument Requested _________________________________________
If an instrument isn't available but a $100 scholarship was offered, would your child be able to participate in the instrumental music program?
Combined household income (before taxes):
Number of people in household dependent on this income: _________
I affirm that all of this information is true and understand that it is subject to verification by ArtsReach. I understand that I will be asked to pay a $30 deposit if awarded an instrument. Fifteen dollars ($15) of this deposit is refundable if the student returns the instrument in good condition.
Parent/Guardian Signature ____________________________ Date _____________
I verify that the above-mentioned student is or will be enrolled in an instrumental music program at my school and I endorse his request to be given an "Instrument from the Attic."
Instrumental Music Teacher ________________________ Date _____________
Every effort will be made to respond to applications within two weeks. For more information, call (410) 996-5424.