Financial Scholarship App JazzArts Charlotte Confidential Application for Tuition SupportSTUDENT INFORMATION:Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of birth(Required) MM slash DD slash YYYY Age(Required)Race (optional)Gender (optional)School (present or rising)(Required)School grade6th7th8thFreshmanSophomoreJuniorSeniorHome PhoneMobile Phone(Required)Email(Required) Instrument/Class Applying For(Required)Teacher (Band or Private Music)PARENT/GUARDIAN INFORMATION (ages 18 & under):Name(Required) First Last Home PhoneMobile Phone(Required)Employer(Required)Childs Emergency Contact(Required)Emergency Contact Phone(Required)How did you hear about JazzArts Charlotte?Please list financial assistance received per year from the following sources:1. What is the Adjusted Gross Income of the person who, for income tax purposes, claims the student(s) listed on this form as a dependent(s)?(Required)Enter amount $:2. What are the total wages of the other parent/guardian?(Required)Enter amount $:3. Do you receive any other allotment of monies from agencies representing:Aid to families with dependent children?Enter amount $:NC public aid: monthly/food Stamps/WIC?Enter amount $:Alimony and/or child support?Enter amount $:Social Security?Enter amount $:Other income (retirement, disability, unemployment, etc.)?Enter amount $:4. Please indicate the total number of children or dependents within your household:5. Enclose a copy of your latest income tax return AND a current pay stub for each wage earner in the family OR any other official proof of annual income (ex: disability, unemployment documentation). Pages 1-2 of 1040, page 1 of 1040A, or SS Form is required(Required) Drop files here or Select files Max. file size: 50 MB. 6. Please write a short statement that explains why the indicated program is important to you and your child. If extenuating circumstances occurred in the past year that hinder your ability to pay tuition in full, you may attach written documentation in support of these claims. Enclose a letter on a separate piece of paper describing any other information you would like to have considered as part of your application. Required: I have read and understand all of JazzArts Charlotte's policies and procedures and agree to adhere to them. I understand that tuition support may be withdrawn from any student who does not maintain a good record of cooperation, endeavor and achievement satisfactory to Jazz Arts Initiative. I understand that this tuition support is granted solely for instruction for summer camp. I understand that providing false or misleading information on any part of this application will disqualify me from any current or future tuition support from Jazz Arts Initiative. Please note that Financial Assistance cannot be granted if this application is incomplete.(Required)Max. file size: 50 MB. Signature:Parent/Guardian or Adult StudentDate MM slash DD slash YYYY
