Application →
Confirmation → Submission
Spring 2024 CCA Scholarship Form
*
Required Fields
Guardian Information
Today's date (mm/dd/yyyy)
mm/dd/yyyy
mm/dd/yyyy
Title (Mx., Ms., Mrs., Mr., etc.)
*Required
Guardian first name
*Required
Guardian last name
*Required
Address
*Required
Address 2
City
*Required
State/Province
*Required
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
*Required
Primary phone
*Required
Email
*Required
Your entry is not a valid email address!
How did you hear about us?
*Required
What is your relationship to the young artist?
*Required
Young Artist Information
Young Artist First Name
*Required
Young Artist Last Name
*Required
Preferred Name
Ethnicity
*Required
Black/African American
Asian/Pacific Islander
Hispanic
American Native/Alaskan Native
Other
White, not Hispanic
Gender
*Required
Female
Male
Other/Nonbinary
Young Artist Date of Birth (mm/dd/yyyy)
mm/dd/yyyy
mm/dd/yyyy
Grade Level in Spring 2024
*Required
Name of School the Young Artist Attends in Spring 2024
*Required
Please check if this is the first class the young artist has attended at Space One Eleven
*Required
Spring 2024
Please select the class for which you are registering your young artist:
*Required
Spring 2024 CCA Grades 2-3
Spring 2024 CCA Grades 4-5
Spring 2024 CCA Grades 6-8 **Waitlist**
Spring 2024 CCA Grades 9-12
The Young Artist MAY be released to the following people (please include full name, phone number, and relationship to young artist):
Is your young artist interested in apply to the Alabama School of Fine Arts (ASFA), if so please check this box:
Emergency and Medical Information
Emergency Contact #1 Name
*Required
Emergency Contact #1 Phone Number
*Required
Emergency Contact #2 Name
*Required
Emergency Contact #2 Phone Number
*Required
In the event of an emergency and the guardian and emergency contacts are not available, does Space One Eleven have your permission to secure emergency medical treatment?
Yes
No
* In the event of an emergency and the guardian and emergency contacts are not available, does Space One Eleven have your permission to secure emergency medical treatment? is required.
If your child has physical or medical conditions or learning differences that might affect their participation in class, please list them here. Please also list any food allergies.
Application for Tuition Assistance
Fees are based on a sliding scale. Through the generosity of foundations and private contributors, your family may qualify for free or reduced tuition. All income information provided here is voluntary, optional, and confidential. Full or partial assistance is available based on financial need, according to federal income guidelines. You will be notified if your family qualifies for tuition assistance and of the tuition rate required if applicable. If you wish to apply, please provide the information below.
Including you, how many people reside at your address?
Total Annual Household Income
Less than $20,000
$20,000 - $30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
$70,001 - $80,000
$80,001 - $90,000
$90,001 - $100,000
$100,001 - $110,00
$110,001 - $120,000
$120,001 - $130,000
$130,001 - $140,000
Greater than $140,001
Privacy Act Statement
This explains how SOE uses the information you share. You are NOT required to give out your financial information, however, SOE cannot consider your child for free or reduced tuition if you choose not to provide the necessary information. SOE will use your information to determine if your child is eligible for free or reduced tuition art programs. SOE may share your information with education, health, and nutrition programs to help evaluate, fund, or determine benefits for their programs, auditors for program reviews, funders, and law enforcement officials to help look into violations of program rules.
Agreements and Waivers
Seats in Space One Eleven's classes for children and youth are limited. I understand that completion of this application does not guarantee enrollment in the class until verified by Space One Eleven staff.
Parental Agreement
I understand that it is my responsibility to provide transportation for my child to and from SOE during those times posted for Spring 2023. I also understand that my child may be dropped off as early as 15 minutes before class starts which will begin promptly at its specified time. I agree to pick up my child when class concludes at the scheduled time. I also understand that it is my responsibility to make arrangements to pick up my child from studio classes in the event that they are sick or disruptive. Sick children will not be allowed to remain at SOE. If a youth is disruptive and asked to leave, they will be allowed to return the following class day as long as they understand that they must practice good behavior. I also understand that the telephones at SOE are for business purposes only and that my child will not call unless it is an emergency. All cell phones and gaming devices will be set aside by the youth upon entering SOE until class ends each day.
COVID-19 Procedures Agreement
I understand that my child and I will follow the COVID-19 policies and procedures put in place by Space One Eleven when attending classes in person. These policies and procedures can be found on Space One Eleven's website under Covid-19 policies. I understand that these policies and procedures may change as Space One Eleven continues to monitor Covid-19.
Artwork Waiver
I understand that any artworks produced by my child in any of SOE's art programs will be disposed of if not collected within 30 days of the end of the program.
Guardian Consent for Media Release
I hereby consent to allow my child to be photographed, videotaped, audio taped, and/or interviewed by the news media during the City Center Art program. Further, I understand that the photograph, videotape, audiotape, or interview transcript may be posted online and/or may be used for publicity purposes in the future. I agree to release and hold harmless SOE, its members, officials, agents, and employees from and against any and all claims, demands, actions, complaints, suits, or other forms of liability that shall arise out of, or by reason of, or be caused by, the use of the image of my child on television, radio, in motion pictures, or in print.
I have read the above terms regarding consent for media release, and:
Yes, I consent and ALLOW my child to be photographed, recorded, or interviewed by SOE or news media.
No I DO NOT CONSENT. My child MAY NOT be photographed, recorded, or interviewed by news media.
* I have read the above terms regarding consent for media release, and: is required.
By entering my name below, I certify that all information on this application is true and that all income is reported. I understand that if I purposely provide false information, my child may lose all program benefits.
Electronic Signature
*Required
Comments
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