Instruments from the Attic

Application

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 $15 deposit if awarded an instrument. This deposit is fully refundable if the student wishes to give the instrument back and returns it 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 _____________

"Instruments from the Attic" is coordinated by a subcommittee of ArtsReach, an arts consortium of the Cecil County Public Schools, and is supported by the Music and Arts Center, Inc. and John and Mary Jo Williams. Every effort will be made to respond to applications within two weeks. For more information, call (410) 996-5424.