Access Application "*" indicates required fields Step 1 of 8 12% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Are you a resident of Franklin County?* Yes No Do you receive any of the following Benefits?Mark all that apply. WIC SNAP Medicaid Number of Tickets You Are Requesting?*Limited to the number of household members. Please list members of your household (including yourself) that you wish to include in your Oyo Access membership. Household members include you, your spouse or domestic partner(s) and children under 18. Household members over 18 for whom you are a primary caregiver (i.e. elder care, those with developmental delays, etc.) also qualify. Information other than name and age is collected for reporting purposes for our granting agencies, and does not impact your acceptance into the Oyo Access ProgramName 1*Age*Highest Education Achieved*N/A - ChildHigh SchoolCollegeGraduatePost GraduateGender Male Female Other/Prefer not to say Add a 2nd Member? Yes Name 2*Age*Highest Education Achieved*N/A - ChildHigh SchoolCollegeGraduatePost GraduateGender Male Female Other/Prefer not to say Add a 3rd Member? Yes Name 3*Age*Highest Education Achieved*N/A - ChildHigh SchoolCollegeGraduatePost GraduateGender Male Female Other/Prefer not to say Add a 4th Member? Yes Name 4*Age*Highest Education Achieved*N/A - ChildHigh SchoolCollegeGraduatePost GraduateGender Male Female Other/Prefer not to say Add a 5th Member? Yes Name 5*Age*Highest Education Achieved*N/A - ChildHigh SchoolCollegeGraduatePost GraduateGender* Male Female Other/Prefer not to say More Members to Add? Yes No Additional Family Members*For each additional member you would like to include, on seperate lines, please enter each member's information. How many people in your household identify as:African American/Black012345678910Latino/Hispanic012345678910Caucasian/White012345678910Asian/Asian American012345678910Disabled012345678910Appalachian012345678910Other012345678910Specify* What is your annual household Income?*Up to $24,999$25,000 to $49,999$50,000 - $74,999$75,000 - $99,999$100,000 or moreWhat is your Zip Code? ZIP Code In order for us to verify your eligibility for our Access program, you will need to upload a picture of your WIC, SNAP, or medicaid card, or a statement from one of the respective programs. You may black out account numbers and the like, but names and a date within the past 3 months MUST be legible.File* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB. Disclaimer and Agreement* I agree to the privacy policy.I certify that my answers are true and complete to the best of my knowledge. I understand that I must provide documentation of my participation in one of the qualifying programs listed above, and that I must present photo identification to receive my tickets at each performance.PhoneThis field is for validation purposes and should be left unchanged. 82293
