Instructions: Print from your browser and mail, fax or bring to : Rogue Gallery & Art Center, 40 S. Bartlett St., Medford, OR  97501

Youth Scholarship Application

Student Name                                                              

Parent’s Name                                                              

Street Address                                                                                                                                     

City                                                                  Zip                                School                                     

Home phone                                                      Cell/Work                                                         

Student age                               Grade Level                               Birthday                       

For which class/camp are you interested in receiving a scholarship?

( A separate form is required for each request.)

Title                                                                                          Dates                                                   

Have you received scholarship assistance at the Rogue Gallery & Art Center before?    Yes     No

            If yes, Class/Camp Title and Dates                                                                                 

Briefly state why you need scholarship assistance:

We ask that families contribute what they can to support the art programs, and contribute something toward their child’s camp. Please indicate below how much you can afford to contribute:

Please indicate the amount you can contribute:

Half Day Camp:   ___$75   ___$50      ___$30      ___$20      Other $_____

Signature of Child                                                           Signature of Parent/Guardian