PLAY ON, INC.
Scholarship Application Form
Play On, Inc. scholarships are available to students of any race, religion, color, national or ethnic origin seeking financial aid to attend a session of music camp, or to take private music lessons. Students must be participating in their public school’s music program and have the support of their public school music teacher.
SECTION A
Scholarship Applicant Information: (Please Print Clearly) Name: ____________________________ Gender: ___ Home Phone: (____)__________
Address: ________________________________________________________________
City: _________________________ County: _____________ State: _____ Zip: _______
School: _______________________________________________ Grade Next Fall: ___
School Address: __________________________________________________________
City: _________________________ County: _____________ State: _____ Zip: _______
Applying for: Summer Music Camp Tuition: ____ Private Music Lessons: ____
Name and Address of Music Camp or Private Teacher: _______________________________________________________________________
________________________________________________________________________
Phone Number and e-mail of Camp/Teacher: ___________________________________
Amount Requested: ___________ Amount is _______% of total cost of Camp/Lessons
Instrument or voice: _________________________ Number of years of Study: _______
Do you take private lessons? Yes: ____ No: ____
If Yes, Name of Current Private Instructor: _____________________________________
Please Submit the Following:
- A brief essay describing your reasons for applying to Play On, Inc.
- A brief written recommendation from your school music teacher.
- A brief written recommendation from your private teacher (if you have one).
- A copy of the summer camp application or a letter of acceptance from teacher.
5. If granted, a follow up letter from the student is required at end of grant term.
SECTION B
Financial Need (to be completed by parent or legal guardian)
If you are receiving Social Security or Social Service benefits, complete the following and send verification of case number (copy of identification card or proof of benefits)
Case Number: ____________________________________________________________
Name of Case Worker: ____________________________ Phone: (____)_____________
If you are not receiving aid through the department of Social Services, complete the following and send verification of income (copy of W2).
Number of dependents in your family (including yourself): ________________________
Gross annual family income (total of all sources of income): $______________________
Please note any extraordinary circumstances that affect your current financial situation (attach separate letter if necessary):
List any organizations you have contacted for additional support:
Signature: _______________________________________________ Date: ___/___/___
Relationship to student: _____________________________
Home Phone: (_____)__________________ Work Phone: (_____)__________________
Send completed form, along with materials from section A to:
Play On, Inc. Scholarships 3 Newbury Terrace Newton, MA 02459
Office Use Only: Received: ___/___/___
Play On, Inc. 