Name _________________________ Age _____ Sex _____
Parent or Guardian's Name _____________________________ Phone ________________ Date ____________
Address ___________________________________________Alt. Phone ________________
City _______________________________ State ____________ Zip _____________
Email Address _____________________________________________
Eligibility Criteria
# of persons in family: 1-3 4 5 6 7 8(or more)
Gross Monthly Income ____________________
Have you taken any Stage IV classes in the past? Yes No
Are you willing to verify this information if requested? Yes No
Please write a 100 word essay below, stating why the Wayne Stage IV Youth Theatre will benefit you, or attach it to a separate sheet of paper.
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