Application Form – Fulton Theatre

School Name*

School Address*

Street Address City ZIP Code

School Phone*

School Fax Phone

Name of Approve School Administrator*

First Last

Must be a principal, assistant principal or curriculum facilitator.

Administrator Title*

Administrator Email*

List known previous participation with Fulton Theatre programs. Specify the school year of each program.

Is your school Title 1?*

Did your school make AYP last year?*

Number of Students in the most recent school year*

% (Percentage) of students on free and reduced lunch in the most recent school year*

School Ethnic Makeup for the Most Recent School Year

Percentage of entire student body.

African American

Asian

Caucasian

Hispanic

Native American

Other

Program Partnership Application

This application should be applied to*

School Day Matinee Bus Funds

If you are applying for these funds, identify the full cost of the buses from school to Fulton Theatre.

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School Day Matinee Scholarship Fees and Neighborhood Bridges Residency Grant

If you are applying for these funds, detail the parameters of your request. How many classrooms at the school would you like us to consider visiting? How many times would you like us to visit?

Primary Contact Name

First Last

Identify a person, if primary contact is different from the authorized school administrator.

Primary Contact Email

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List

Teacher Email

Identify all classroom teachers who will be impacted if your school is named a EITC Program Partner.

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School Partnership Brief Statement of Goal and Mission*

What are your goals for the partnership? How do you see Fulton Theatre supporting student learning? How will you assess the impact of the program?

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"Memo of Agreement."*

I understand that my application is not complete until I mail a signed copy of the “Memo of Agreement.”

Download this memo from the EITC Program page on the Fulton Theatre website.