Urban Artisans Application
First Name *
Your answer
Last Name *
Your answer
Session
Address *
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City *
Your answer
State *
Your answer
Zip *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Social Security Number *
Your answer
Date of Birth *
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Gender *
Emergency Contact Name *
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Relationship to you *
Your answer
Current School *
Your answer
Current Grade *
Your answer
Race *
How many people (including yourself) live in your household? *
Your answer
Who do you live with? *
Do you participate in a reduced lunch program at school? *
Do you, your family or household receive any of the following *
Required
What is the yearly income range of your household or family: *
Do you have a diagnosed disability? *
Required
By submitting this application I do hereby agree that any artwork that I produce in whole or in part as a participant in the Urban Artisans program, including, but not limited to, any and all paintings, sculptures, pottery, literary works, musical compositions, or recordings, are and shall remain the property if Urban Artisans, and I have no proprietary interest in said work. *
I understand that the artwork that I produce may be used for publicity and/ or sold to fund the Urban Artisans program. *
Photo Release and Medical Release
Please be sure to fill out the photo release and medical release forms with an ArtMix staff member.
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