Scholarship

Date of Application___________________

Ballet Western Reserve

Scholarship Application

Father’s Name______________________________________Home Phone_________________

Address/City/State/Zip___________________________________________________________

Place of Employment_________________________________Bus. Phone__________________

Address/City/State/Zip___________________________________________________________

Salary______________________ Monthly Gross______________________

Marital Status: Married Single Separated Widowed Divorced

Mother’s Name______________________________________Home Phone_________________

Address/City/State/Zip___________________________________________________________

Place of Employment__________________________________Bus. Phone_________________

Address/City/State/Zip___________________________________________________________

Salary______________________ Monthly Gross______________________

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Other Income Sources: (monthly) –Please state amount – verify by enclosing most recent 1040 form.

Child Support $______________ S.S.I. $______________

Alimony $______________ A.D.C. $______________

Unemployment Comp . $______________ Social Security $______________

Workmen’s Comp. $______________ Pension $______________

Interest and/or Dividends $______________ Salaries $______________

Total Income $______________

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Children:

Name Birthdate Age Grade School District Classes enrolled in at BWR
Students enrolled at Ballet Western Reserve

**Note: Unless a Company or Apprentice Member: Scholarships cover a maximum of two classes per child.

__________________________________________________________________________________

Other children not enrolled at Ballet Western Reserve

__________________________________________________________________________________

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Monthly Expenses:

Do you _________Rent _________Own

What type and year vehicle(s) do you drive? (1)Type_______________Year__________

(2) Type_______________Year_________

Mortgage Rent $______________ Medical Insurance $______________

Household Expenses $______________ Other Insurance $______________

Utilities $______________ Medical Expenses $______________

Food $______________ Educational Exp. $______________

Other $______________ Charge Accounts $______________

Car Insurance $______________ Car Payments $______________

Total Estimated Monthly Expenses $______________

Net Income $______________

**********************************Extra-curricular Activities:

Do you participate in any other extra-curricular activities? Please indicate.

______________________________________________________________________________

Do you receive scholarship assistance for any other activities? Please indicate.

Activity________________________________Amount________________________________

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If there are extraordinary circumstances in your financial situation which you feel would be helpful to us in making a determination
of an adjusted fee, please state here:

______________________________________________________________________________

Certification

I declare that the information provided herein, to the best of my knowledge, is true, correct, and complete. I understand that
all information will remain confidential.

__________________________________

Signature

__________________________________

Date

Return all forms to: Ballet Western Reserve, P.O. Box 1684, Youngstown, Ohio 44501-1684

Office Use only

Date form received__________________

Dispostion_________________________

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Ballet Western Reserve Scholarship Contract

The Ballet Western Reserve expects its scholarship students and their parents to be an active part of this organization. Your time and assistance in the Ballet Western Reserve building and at performances is expected. The following is a list of requirements for all scholarship parents and students of an appropriate age.

1. Students must attend 80% of all scheduled classes and rehearsals. If absences exceed 20%, a formal doctor’s excuse must be submitted to the Ballet Western Reserve office upon the student’s return.

2. Each student is required to sell a minimum of five ads for each performance program in which advertising is included. All ads and payments must be returned to the Ballet Western Reserve office on the scheduled due date.

3. Students and parents must be available to help with fundraising efforts. This includes, but is not limited to, assisting with mailings and telephone calls.

4. Students and parents must be available to help with boutique sales in the Ballet Western Reserve building and at performances.

5. Parents must be available for volunteer work at performances. This includes, but is not limited to, ushering, backstage work, set up, tear down, transportation of sets and costumes and publicity work.

6. Parents and students must be available to help with general school projects as needed.

Please sign below:

I have read the above and am willing to participate in all of the scholarship requirements listed. I understand that failure to fulfill this contract may result in suspension of scholarship. I understand that signature of this form does not guarantee a scholarship will be awarded by the Ballet Western Reserve.

Parent Signature_________________________________________Date________________

Student Signature________________________________________Date________________

**Please keep the second copy of this form for your records and reference.