Form

Mother's Name *

First Name Last Name

Father's Name *

First Name Last Name

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

E-mail

# in Household *

# of Dependents in Household *

Years at this Address *

Father's Occupation *

Father's Annual Income ($) *

Mother's Occupation *

Mother's Annual Income ($) *

Other Income Source(s)

Other Income ($)

Briefly state your need for assistance *

Please attach copies of your: (a) 2012 IRS Form 1040 (first page only) and (b) 2012 W-2 Wage statement(s) and/or 2012 Form 1099(s).

2012 IRS Form 1040 *

2012 W-2 Wage Statement #1 *

2013 W-2 Wage Statement #2 (if applicable)

Please read each item below and enter your initials in the box to signify your agreement.

FINANCIAL RESPONSIBILITY - I understand that I will be financially responsible for my family's total registration cost minus any potential Financial Assistance awarded.

Enter initials here *

CANCELLATION PENALTY - I have read and understand the Cancellation Policy outlined on the Music Together with CCSA website. I further understand that, if I withdrawl my family from participation in Music Together with CCSA, any Financial Assistance awarded to my family will be returned to the Organization and will not be considered as part of the amount on account for purposes of refund calculation.

Enter initials here *

Please sign the application. Typing your name in the fields below indicates an electronic signature.

I understand and agree to the terms outlined above. *

First Name Last Name

Date of Submission *

- Month - Day Year

at

: Hour Minutes

MT with CCSA Financial Assistance Online Application