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Date Received: _________

Please print both pages and fill out as completely as possible. If you have questions or concerns about the information requested, please call CSMA at 272-1474

Note: There is a limit of two areas of study per person, per term. Scholarship recipients can take private instruction with one teacher plus one class, OR up to two classes per term. Student (youth & adults) for whom this application is being made should be listed below.

Name Date of Birth

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ List any additonal dependents other than the students named above. Name Date of Birth ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Parent/Guardian (or Adult Student) _____________________________________________

Address _________________________________________ Phone _______________________________ City _________________________ State _____________ Zip _______________ Email ________________________________ Employer ____________________________________ Work phone ___________________________

Other Adult Household Member ________________________________________________

Employer ____________________________________ Work phone ______________

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