DEMOGRAPHIC FORM

DEMOGRAPHIC FORM

"*" indicates required fields

2022-2023 ENROLLED STUDENT/FAMILY DEMOGRAPHIC INFORMATION FORM ALL INFORMATION IS KEPT CONFIDENTIAL

Each participant in this program is required by Broadway School of Music & Arts and the City of Cleveland, Department of Community Development to provide their annual income level to establish eligibility for this federally-funded program, and to verify race/ethnicity for data collection purposes only.

From the income characteristic listed below, please circle the number of persons in your household and the annual income level that matches your household size. Check the appropriate box for race and for ethnicity, when applicable. Sign your name to verify the information you supplied to the Agency is true.

Income Characteristics

Number of Persons in Household*
(Circle One)
Extremely Low Income (0 to 30% of MFI), $
(Circle One)
Very Low Income (31% to 50% of MFI), $
Low Income (51% to 80% of MFI), $
RACIAL CHARACTERISTICS (Check One)
RACIAL CHARACTERISTICS*
ETHNICITY
MM slash DD slash YYYY