Ballet Hispanico School of Dance
Scholarship Application for Summer 2012
Please print all information
Student Information:
Last:
First:
Previous Scholarships:
School Name
Middle Initial:
Please list all previous merit or need‐based scholarships granted by Ballet Hispanico or other dance schools.
Amount of Scholarship
Year(s) Scholarship Awarded
$
$
$
$
Household Income:
Name
Please list all persons, related and non‐related, who live in the household and share living expenses.
Occupation and Title
Total Income reported on IRS 1040
Current Employer $
$
$
Additional annual income from other sources:
$
Amount able to contribute toward tuition:
$
Dependent Children:
p
Childʹs Name
Please list all dependents living in the household or living outside your home, and indicate the amount
ea e i a epe e
i i gi
e ou e o o i i g ou i e you o e, a i i a e e a ou
of financial assistance received each year from extra‐familial sources.
School Amount of Financial Assistance
Age
$
$
$
$
Additional Information:
Student Response
Please use the space below to describe any extenuating circumstances or additional information not reflected in this application or on your 1040 or 1040EZ form.
In what way will your studies at Ballet Hispanico enrich your life? (Feel free to add additional pages) Certification: I certify that all of the information provided is true and that all household income is reported.
I understand that incomplete information will hinder the scholarship process for my child. I understand that
the information contained in this merit application will be kept confidential by Ballet Hispanico.
Parentʹs Signature
Date
Please sign and date this form and return to the address below. You must include a copy of the 2011
IRS 1040 or 1040 EZ Tax Return Forms for each person listed in ʺHousehold Incomeʺ above.
Return to: Nicholas Villeneuve, Deputy School Director, Ballet Hispanico, 167 West 89 Street, New York, NY 10024
167 WEST 89TH STREET, NEW YORK, NY 10024 TEL: 212-362-6710 FAX: 212-362-3081 WWW.BALLETHISPANICO.ORG