WORKING CLASSROOM`S PROGRAM APPLICATION

WORKING CLASSROOM`S PROGRAM APPLICATION

OFFICE USE: Amount/Form paid _______________________
Date:_______________________
Received by: _______________________
Referred by (optional): _______________________
423_Atlantic SW, Albuquerque, NM 87102 (505) 242­9267
WORKING CLASSROOM’S PROGRAM APPLICATION
Application checklist:
☐ Program application / Solicitud para el programa
☐ Scholarship application / Solicitud para la beca
☐ Most current report card / Calificaciones
☐ Sliding scale registration fee / Matrícula ($10, $25, $50, $200)
☐ Parent signature / Firma de padres
☐ (Optional) CHECK HERE IF RECOMMENDED FOR A FULL­SCHOLARSHIP AND INDICATE NAME OF RECOMMENDER:
______________________________________________________________________________________________________
Name of recommender AND Relationship to student
Thank you for applying to Working Classroom. To help us review your application, please provide the following
information / Gracias por matricularse al programa de artes de Working Classroom. Para ayudarnos a evaluar su
solicitud, por favor entregue la siguiente información:
Working Classroom program application /
Solicitud para el programa de Working Classroom
New student / ¿Alumno nuevo? ☐ Yes/ Sí ☐ No
Interests/Intereses
☐ Theater/teatro ☐Visual Arts/artes visuales
Name/Nombre_________________________________________________
Address/Dirección:______________________________________________
City/Ciudad: ____________________ State/Estado:_______________ Zip Code/Código Postal: __________
Email/Correo electrónico__________________
Phone/Telfono ____________________ Cell Phone/Número celular___________________________
Birth date / Fecha de nacimiento_________________________ Age / Edad_________
Male / Hombre ☐ Female / Mujer ☐ Race and Ethnicity / Raza étnica_____________________________________
School / Escuela_______________________________________________________Grade / Grado _________________
Parent or Guardian Information:
Parent or guardian’s name/ Nombre del padre o tutor:
_______________________________________________________________
Parent or guardian’s work phone / Teléfono del trabajo del padre o tutor:
_______________________________________________________________
In the event of an emergency call (name, relation) / En caso de emergencia llame a (nombre, relación):
_______________________________________________________________
At the following numbers / A los siguientes teléfonos:
_________________________________________________________
Do you have allergies? / ¿Tiene alergias? Yes / Si ☐ No ☐
If yes, please explain / Si la repuesta es si, explique
_______________________________________________________________
Do you have any other medical conditions we should know about? Ex. diabetes, epilepsy, etc./¿Tiene alguna restricción
médica que debamos saber? Por ejemplo: diabetes, epilepsia, etc.:
_______________________________________________________________
_______________________________________________________________
List any type of medication you are taking / Enumera los medicamentos que esté tomando actualmente:
_______________________________________________________________
_______________________________________________________________
List any visual art or theater experience / Describa sus experiencias en artes visuales o teatro:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Return this completed application with your tuition /
Por favor entregue la solicitud rellenada por completo con colegiatura.
____________________________________
Student Signature/ Firma del estudiante
_____________________
Date / Fecha
____________________________________ ____________________
Parent Signature / Firma del padre, madre o tutor
Date / Fecha