VSA arts of Nevada Scholarship Application
PRE-REGISTRATION REQUIRED FOR ALL CLASSES
Please send application with registration form to VSA arts of Nevada. Phone 826-6100
Fax to 337-6107 or mail to 250 Court St, Reno, NV 89501

Name: __________________________________Date: __________

Address _______________________________________________

City, State, Zip ___________________    Phone_________________

Employer ___________________         Work Phone _____________

Cell #________________________                         

E-mail: _______________________________________________

If application is for a child, please complete next section.

Name ______________________________ Age ______________ 

School _____________________________ Grade _____________

Please list class(es) that you are interested in taking,  including date and location. 

____________________________________________________________

Do you/your child have a disability?   ____________________________

Household monthly gross income from employment  __________________ 

# of people in your household __________________ 

List any other sources of household income or public assistance and monthly amount 

________________________________________________________________

Amount requested:  $____________  Amount you can contribute: $____________

Participant/Parent/Guardian Signature _____________________________________