Heights Arts receives a community development block grant from the federal government administered by the City of Cleveland Heights. If your family income level, taking into account the number of persons in your family, falls below any of the levels in the table below, then your children are eligible for the indicated class fee.

We must provide certain demographic information about our enrolled students in order to receive these funds. Your name is never given to our funding agency: the information is presented in a summary form for data collection purposes only. If you are eligible you must fill out this form to receive the financial aid.

1. Please select number of persons in the household: (scroll down to find applicable answer) 2 3 4 5 6 7 8 9


2. Please select below which level your household* income falls according to the table below: (scroll down to find the applicable lowest level) *Household includes all persons living in your home. Level 1 Level 2 Level 3

   Income by household size eligible for reduced class fee.

   Household Income	2 person	3 person	4 person	5 person	6 person	Class Fee
   Level 1	$14,900	$16,800	$18,650	$20,150	$21,650	$5
   Level 2	$24,850	$27,950	$31,050	$33,550	$36,000	$10
   Level 3	$39,750	$44,750	$49,700	$53,700	$57,650	$20



3. Is your household headed by a single female? No Yes


4. Please select which of the following most closely describes your racial and ethnic background (scroll down to find applicable answer)
   White African American American Indian or Alaska Native Asian Native Hawaiian or other Pacific island   American Indian or Alaska Native and White Asian and White African American and White American Indian or Alaska Native and Black Other Multi-Racial

Student name:


Parent/Guardian signature:

Date: