Apply for a Youth Scholarship_Fall-Spring

Name

Date of Birth (used to confirm program eligibility)

Parent/Guardian (if student is under 18)

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Email Address

Name of Class(es)/Camp(s). Please be specific, ex: Week 1, June 17-21: Pottery (Ages 6-8)

Class/Camp Start Date

Please describe your current financial situation

What do you hope to gain by participating?

Scholarship Amount Requested

It has been our experience that those who contribute to the tuition feel more invested in the class.

Are you able to contribute toward the fee? (If yes, list amount)

Photo Release: I grant permission for the City of Burlington or its agents to photograph or record my child's image or voice, during programs and activities, without payment or consideration. I understand that any such photographs or recordings will become the property of the City of Burlington. By selecting this box I am agreeing to the above. Additional details can be found in the Assumption of Risk and Waiver of Liability.

Yes

Artwork Release: I grant permission for the City of Burlington or its agents to photograph or reproduce images of my child's artwork, during programs and activities, without payment or consideration. I understand that any such photographs or recordings will become the property of the City of Burlington. By selecting this box I am agreeing to the above. Additional details can be found in the Assumption of Risk and Waiver of Liability.

Yes

I agree to FULLY read and complete the following fields in their entirety with all requisite information for my child with the understanding that the fields below are required and serve as a digitized Student Information Form and therefore will not need to complete additional paperwork. Should information change, I agree to contact BCA staff directly ASAP to make changes prior to the start of the program.

Does your child have a preferred name?

Please list the full name and phone number for Parent 1.

Please list the full name and phone number for Parent 2.

Please enter the full name, relation, and phone number of any additional individuals, other than parent/guardian, that may pick-up your child(ren) and be contacted in an emergency. In case of an emergency, BCA will contact both parents prior to contacting the individuals listed.

I grant my child permission to leave the premises for the following situations. Check all that apply. NOTE: Chaperoned walking field trips such as guided photo walks, painting en plein air, etc. are included in some program curriculum. If you do not grant permission for your child to leave on their own they must enroll in Lunch Coverage as applicable.

Chaperoned Walking Field Trips

Leave Premises for Lunch Break

Leave Premises on Own at End of Day

My child does not have permission to leave the premises

Will your camper be bringing medication that needs to be administered during camp? If yes, you will be asked to upload the BCA Medication Administration Form document to your Civic Rec account below before camp starts.

Yes

Download the Medication Administration Form

We strive to create a joyful experience for all program participants. Is there information that would be useful to share to enhance the participant's learning experience?

Please tell us more about the scholarship recipient and your household! We are committed to creating a diverse and inclusive organization. The following section is optional, but your information will help us greatly in developing future programs and events. Thank you! Your privacy matters to us. Your information will never be shared or sold.

Age

6-10

11-17

18-25

26-45

46-65

65+

Gender

Female

Male

Non-Binary

Self-Identified:

Do you work in the city of Burlington?

Yes

Which of the following statements best describes your household’s financial situation:

Struggling

Struggling, but living paycheck to paycheck

Doing OK within a set budget

Making enough money to get by, worry only occasionally

Do not worry about money

Protected Classes (Select all that apply)

Veteran or Active Duty Personnel

English Language Learner

Living with a Disability

Living below the Poverty Line

Living in non-traditional housing (such as a hospital, assisted care facility, homeless shelter or other transitional housing facility)

None of the above

Self-Identified:

Race/Ethnicity (Select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Prefer not to say

Self-Identified:

BCA’s Education Director is usually able to process scholarship applications in a week’s time (or less) and will be back in touch. Questions? Contact BCA Education Director Melissa Steady: msteady@burlingtoncityarts.org