Black Box Theatre Company
378 N Mt Zion RoadLebanon, IN 46052
Please include as much information in your application as possible. The more the Scholarship Committee understands your personal situation, the better educated they are to make a final decision.
Today's Date*
Have you completed a full scholarship application, including all financial information and references, within the last 12 months?* YesNo
Are you a high school student applying independently due to lack of financial support from a parent or guardian?* YesNo
Parent Name*
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Address*
Phone*
Email*
Employer*
Employer Phone*
Longevity with Employer*
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Add Secondary Parent Information? YesNo
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Secondary Parent Name*
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Address (if different)
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Number of dependents living in home? 123456
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Name*
Age*
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Number of applicants? 123456
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Camp/Workshop/Class/Show?* —Please choose an option—CampWorkshopClassShow
Percentage you are asking?* —Please choose an option—25%50%75%100%
Name of Camp/Workshop/Class/Show (if known)
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A minimum of two references is required. Please include friends, employers, or clergy that you would give as references.
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Do you have any personal connections to Black Box, such as a family member who teaches or serves on the Board of Directors? YesNo
[group affiliation] Please list all affliations.* [/group]
State the value or benefit you feel your child(ren) and family receive from Black Box Theatre.*
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Please list other public assistance programs and/or scholarships that any member of the family receives for other extra-curricular programs.*
What circumstances, if any, have led you to apply for a scholarship?*
In your most recent tax filing, did you file tax form 1040? YesNo
[group taxform-1040] Provide line item #7.* [/group]
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What tax form number did you file?*
Line item #?*
Line item amount?*
The following sections show a general breakdown of your monthly expenses.
If a particular section is not applicable, just put NA.
Mortgage/Rent*
Car, Student, or Other Loans*
Healthcare Payments*
Living Expenses (Utilities, Credit Card Payments, Groceries, etc.)*
Other Costs*
[group costs] Please Explain Other Costs [/group]
We require a copy of your latest tax form AND two most recent pay stubs in order for your scholarship application to be complete.
Applicants that have not given this information will not be considered by the Black Box Scholarship Committee.
Prior to submitting these documents, please obscure any tax id numbers.
You may choose one of the following three methods to submit this information:
Upload documents using this form (Preferred)
Email documents to Black Box President
Arrange a time with Kelley Johnson to drop off paper copies at Black Box
These are the only three options for submission and must be completed 10 days before the start date of the class or show.
Additional Comments
By checking the box you are agreeing to the following:
We (I) understand that financial scholarships are awarded based on application, availability, and need. Financial scholarships are partial scholarships, in that, a portion of the tuition fees are paid by the scholarship.
We (I) understand that we are responsible for the remaining registration fee.
We (I) understand that we may be called upon to volunteer during theatre functions, using our time and talents.
We (I) will abide by tuition policies as set forth by Black Box Theatre.
We (I) Agree.
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