Apply for a Youth Scholarship | Burlington City Arts

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

What do you hope to gain by participating?

BCA is committed to supporting participation for all and to reserving significant financial assistance for our most vulnerable citizens. Our scholarship policy aims to support as many individuals as possible with limited funds, which may result in an annual scholarship award cap per applicant. If you are requesting financial assistance, please select the amount below.

25% - Check this box if you can almost fit this program into your budget but need a little help.

50% - Check this box if you live within a strict budget and need extra support.

I qualify for BED Energy Assistance; Vermont Seasonal Fuel Assistance; 3SquaresVT; VGS Energy Assistance; Vermont Section 8 Assistance and need a full scholarship.

I am not requesting a scholarship

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/guardian 1.

Please list the full name and phone number for parent/guardian 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. Check all that apply. NOTE: Chaperoned walking field trips are included in program curriculum; minors (under 18) will not be permitted to leave the site without an approved advanced permission from the parent/guardian.

Chaperoned Walking Field Trips

Leave Premises for Lunch Break

Leave Premises on Own at End of Day

Will the student 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

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

Special thanks to the generous community members who make BCA scholarships possible!