Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Information About You

In this section we will ask basic questions about you to enable us to report to the grant agency on who benefits from this program. We will not share this information outside of statistics provided to the grant agency. In order to be eligible for the pay what you can afford program, you must indicate that the program will enable you to take classes and learn skills that you would not have been able to afford if you paid the full course tuition.

What is your race? *

Black or African American

American Indian or Alaskan Native

Asian

Hawaiian or Pacific Islander

White

Are you of Hispanic, Latino, or Spanish Origin? *

Yes

No

Are you living with a disability? *

(deafness, blindness, difficulty concentrating, remembering, or making decisions, mobility issues)

Yes

No

Is your annual household income more than or less than $35,000? You may still be eligible even if your household income is above $35,000. *

More than $35,000

Less than $35,000

Would the Pay What You Can Afford Program help you to afford the classes or membership offered at the 510 Art Lab? *

Yes, I could not afford to participate in the 510 Art Lab activities without a discount

No, I could afford participation in the 510 Art Lab activities without a discount

Are you interested in membership or class tuition? *

Year Membership

Class Fees/Tuition

Date of the class you selected:

MM

DD

YYYY

How much of the above selection (Class or Membership) are you able to pay? *

20%

40%

50%

60%

80%