First Act, Inc.

First Act Scholarship Program

2009 Application

Please submit the completed application form, along with a description of your financial situation by February 16, 2009.

*Please Note* This form is only used for First Act scholarship applicants. You must also submit a completed application along with all required materials to the Heifetz Institute. An application form for the Heifetz Institute can be found at www.heifetzinstitute.org

Required fields are denoted in bold and italic

Personal Information
Name
Date of Birth
Grade
Age (as of June 26, 2009)
Male / Female	male female
Annual Household Income
Current Address
Address
Address 2
City, State, Zip
Home Phone
Cell Phone
Email
Permanent Address (if different than above)
Address
Address 2
City, State, Zip
Home Phone
Cell Phone
Email
Additional Questions
Please describe your financial situation and why you would like to attend the Heifetz Institute (75-100 words). Any information you can provide will be helpful in determining your eligibility for a First Act Scholarship.

How did you hear about the First Act Scholarship?

Student's Signature: Please enter your initials in lieu of a signature. By entering your initials, you are giving First Act permission to review the information contained herein for the purposes of the scholarship application only. First Act does not share information with any entity other than the Heifetz Institute.

Parent's Signature: Please enter your initials in lieu of a signature. By entering your initials, you are giving First Act permission to review the information contained herein for the purposes of the scholarship application only. First Act does not share information with any entity other than the Heifetz Institute.