Exit Scholarship Request: Multimedia Design Studio Question Title * 1. Student Name (First Name, Last Name) Question Title * 2. Student Age 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old Question Title * 3. Parent/Guardian Name (First Name, Last Name) Question Title * 4. Parent/Guardian Cell Phone Question Title * 5. Mailing Address (Street, City, Zip Code) Question Title * 6. Question for Student: Please tell us why you are interested in this program and what you hope to get out of this experience. Question Title * 7. Does the student have any dietary restrictions? Question Title * 8. Does the student have any allergies? Please let us know if the student requires any medical treatment during the program (allergy medicine, etc) Question Title * 9. May we use photos or video which include your student in Westcott communications? Yes No Question Title * 10. Students who receive the scholarship will receive a free tuition to this program. Please certify that the student will make an effort to attend all the sessions. The scholarship will make it possible for my child to attend the program. My child will make an effort to attend all the sessions. Question Title * 11. At the end of the program we will ask each student to write a short testimonial evaluating the value of the program (we will use testimonials to communicate the impact of our programming to our constituents and seek grant funding to offer scholarships for future programs) The student commits to contributing a short testimonial/evaluation at the end of the program Done