Instruments from the Attic


Student's Name _________________________________________

Address _________________________________________

City/State/Zip _________________________________________

Home Phone ___________________ Date of Birth ______________________

School _________________________________________

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?

Yes No If no, why

Combined household income (before taxes):

$0 - $10,000 $10,001-$20,000 $20,001-$25,000
$25,001 - $30,000 $30,001-$35,000 $35,000 +

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.