Keoni Movement Arts Scholarship Application
Instructions
Thank you for your interest in applying for financial assistance from Keoni Movement Arts! Please fill out this form so that we may make a determination of the level of financial assistance we can provide for you. Income verification documents are to be submitted separately. If you are granted a scholarship, you must fill out a signed agreement upon receipt in order to receive the assistance. Note: there is an annual program registration fee of $25, which is to be paid along with the scholarship amount that is determined. If you have any questions, please email us at info@keonimovementarts.org or call 212.643.9013.
Child's First Name - (if not applicable, input n/a) *
Your answer
Child's Last Name - (if not applicable, input n/a) *
Your answer
Parent's First Name (or use this field if you're applying for yourself) *
Your answer
Parent's Last Name (or use this field if you're applying for yourself) *
Your answer
Address *
Your answer
Telephone *
Your answer
Email *
Your answer
Date *
MM
/
DD
/
YYYY
Which KMA program will this person be enrolling in? *
Please tell us why you're applying for this financial assistance, and how receiving this scholarship will benefit you and/or your child. *
Your answer
Please indicate total annual household income from all sources. *
Financial documents verifying income - check at least two. (Note: you may submit these to admin@keonimovementarts.org or hand to us in-person. All information will be kept strictly confidential and will be used only for the purpose of verifying income. Photos of documents may be submitted.) *
Required
Number of Dependents listed on Taxes (or if not filing taxes, state why). *
Your answer
Number of Persons in Household *
Your answer
Where does your child go to school? (if not applicable, put in n/a)
Your answer
If your child goes to public school, do you qualify for the free lunch program?
If your child is enrolled in Pre-K, do you qualify for Head Start?
Does your child have a Medicaid Waiver?
Is your child enrolled in Self-Direction through OPWDD?
Your or your child’s ethnic and racial background is (check all that apply): *
Required
Parent Martial Status *
Please tell us any other extenuating circumstances you would like us to know about.
Your answer
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