Does the child qualify for free lunch?
Does the child qualify for reduced lunch?
Does the child live in a single parent household?
Do you receive public assistance?
Are you a foster parent to this child?
Does the child or head of house have a disability?
Is the head of household elderly? (65+)
Certification
The applicant certifies that all information in this application is true to the best of his/her knowledge and belief and no information has been excluded which might reasonably affect a judgment regarding the applicant's eligibility. Signing this application will give the Gloucester Community Development Grants office the right to obtain verification from any source herein.
Penalty for false or fraudulent statement U.S.C
"Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies or makes any false fictitious or fraudulent statement or representations or makes or uses any false writing or entry, shall be fined not more than $10,000 or imprisoned not more than five (5) years or both."
Classes
Please check off classes you would like to take:
Artist's Name (include nickname if needed)
Artist's Name (include nickname if needed)
Address
Address
Parent/Guardian Name 1
Parent/Guardian Name 1
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Parent/Guardian Name 2
Parent/Guardian Name 2
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
I would like to be added to the mailing list to receive updates about Art Haven programs.
(This information is confidential and will not be shared with any other party)
I give permission for my child to attend Cape Ann Art Haven.
Emergency Consent Form
If you cannot be reached, and in order for Cape Ann Art Haven to protect your child in the event of a medical emergency, please complete and sign the following information. This form will accompany your child to the hospital so that medical treatment can be provided. I hereby authorize Cape Ann Art Haven staff to give consent for any emergency medical and/or surgical treatment deemed necessary for my child during class hours:
Student's Doctor
Student's Doctor
Doctor's Phone
Doctor's Phone
Date of last tetanus shot
Date of last tetanus shot
If so, please describe.
Transportation
Please list names.
My child my accompany the group, with the supervision of Cape Ann Art Haven staff, out of the Art Haven studio for field trips. (The only means of transportation would be walking.)
I give permission to have my child photographed during Art Haven classes for the purposes such as bulletin boards, newsletters, brochures, promotional materials, or grant applications.
I give permission for my child's artwork to be photographed for purposes such as bulletin boards, newsletters, brochures, promotional materials, or grant applications.

Once your application has been submitted, the Art Haven staff will contact you on the status of your application.