Address*

Secondary Parent Information

Secondary Parent Name*

Dependent Information

Number of dependents living in home?
123456

Applicant 1

Name of Camp/Workshop/Class/Show (if known)

Applicant 2

Name of Camp/Workshop/Class/Show (if known)

Applicant 3

Name of Camp/Workshop/Class/Show (if known)

Applicant 4

Name of Camp/Workshop/Class/Show (if known)

Applicant 5

Name of Camp/Workshop/Class/Show (if known)

Applicant 6

Name of Camp/Workshop/Class/Show (if known)

Reference Information

A minimum of two references is required. Please include friends, employers, or clergy that you would give as references.

Reference 1 Information

Name*

Address*

Reference 2 Information

Name*

Address*

Black Box & You

Do you have any personal connections to Black Box, such as a family member who teaches or serves on the Board of Directors?
YesNo

Financial Information

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

Monthly Expenses

The following sections show a general breakdown of your monthly expenses.

If a particular section is not applicable, just put NA.

Living Expenses (Utilities, Credit Card Payments, Groceries, etc.)*

Other Costs*

Financial Documents

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:

1. Upload documents using this form (Preferred)

2. Email documents to Black Box President

3. 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.