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Franklin County Senior Citizens

Concert Series

Agency Application

1.     Name of Agency:  ___________________________________________

2.     Authorized Representative:  ___________________________________________

3.     Address:  _______________________________________ Tel. _______________

4.     Do you request a live Concert at your facility?    Yes ___*     No ___

*If Concert Requested, Band Preferred:       

          Town Band (65 musicians) ___

          Swing Band (18 musicians) ___

          German Band (16 musicians/6 dancers) ___

          Small Ensemble  (4 to 8 musicians) ___

[Please estimate number of seniors anticipated at Concert, if requested: ______ ]

Do you request funding to transport seniors to/from a regular SB Concert?   

Yes ___           No ___       

(FCSCCS stipends are $3 per mile for each FranklinCounty agency to transport seniors to/from SB concerts in the community.)

Signature of Authorized Representative _____________________________________

Date: __________________

[Mail Completed Application To: FCSCCS, 62 Independence Drive, Shippensburg, PA 17257 or attach and email to fcsccs@shipband.org]