The Beyond Technique Residency 3 - Expression of Interest Application Form

The Beyond Technique Residency #3 - Expression of Interest Application Form

Application Deadline - October 18, 2015
Read and follow the instructions carefully prior to submitting your application.
I have read and understand the instructions.
All correspondence will be generated from the personal information submitted below. So, please use correct spelling, capitalisation and punctuation.
I. Contact details:

Tell us about yourself
Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Home Address :

Street Address

Street Address Line 2

CityState / Territory

Post CodeCountry
E-mail :
Where the confirmation will be send to
Mobile No. :

Area CodePhone Number
Telephone No. :

Area CodePhone Number
Birthdate:

MonthDayYear
Do you require assistance filling out this form?
If you answered Yes, what is the full name of person filling out this form

PrefixFirst NameMiddle NameLast NameSuffix
Relationship to applicant:
Mobile No. :

Area CodePhone Number
Telephone No. :

Area CodePhone Number
E-mail :
Where the confirmation will be send to
II. Dance Experience:
Short biography (200 words):

0/200
I am currently:
Dancing as a hobby (non-professional)?
If Yes, where?
Studying at a pre-tertiary / tertiary-level dance institution?
If Yes, where?
A recent graduate?
Course Attended / Attending:
Other:
Year of Graduation:
Working indpendently?
Working with a company?
Name of company:
Have you previously worked with Philip Channells ?
Have you previously worked with Lee-Anne Litton?
III. Availability and Interest:
I wish to attend The Beyond Technique Residency #3
I am available between Sunday 1st - Sunday 8th November 2015
I would like to attend only part of the residency
Dates available:
I am interested in disability-inclusive dance practice
I am interested and available to volunteer throughout the week.
IV. Accommodation:
I require single room accommodation (extra $100)
Comment:
I am happy to share twin accommodation with another artist
Comment:
I sleep with the light on
I'm told I snore loudly
I have specific access needs and would like to attend the BTR#3 with a friend / colleague / family member who will support me during my stay and share a twin room.
Family member, Friend or Colleague?
Support person's name

PrefixFirst NameMiddle NameLast NameSuffix
E-mail
Phone Number

Area CodePhone Number
Participant in the project
V. Dance Practice:
I am interested in developing:
I am happy to work in Either group
Preference:
VI. Acceess Requirements:
Do you have a disability?
Comment:
Preferred method of contact
If Other, comment:
I have access requirements?
Comment:
I have medical requirements?
Comment:
I have dietrary requirements?
Comment:
I need transport assistance to Bundanon Trust's Riversdale Property?
How do you plan to get to Riversdale?
I would like to discuss my access & transport needs, medical & dietary requirements and any other support needs I have through my preferred method of contact.
Comment:
VII. Financial Investment
Early bird EOI applications are eligible for $100.00 discount.
I would like to secure my place with an initial $100.00 payment
NOTE: A Financial Agreement Form will be emailed to you to once we have processed your application. Please check you have provided us the correct email account details.
Early Bird / EOI received before Fri 25 September 2015
General / EOI received between Sat 26 September – 18 October 2015
I would like to apply for a payment plan.
I agree to pay in full by 5pm Monday 26 October 2015
VIII. Additional information
Any additional information you would like us to know:

0/500
IX. Authorisation and Consent
I have read and understood the information regarding The Beyond Technique Residency #3 and give my consent to participate and be photographed / videod for promotional purposes. I also consent for contact bewteen Bundanon Trust and Dance Integrated Australia staff and volunteers to take place.
I understand that any bullying, sleeping in an undesignated accommodation, failing to co-operate with the collaborators and artistic process and any other inapproriate behavior deemed to have a negative impact on my or other particpant’s health & well being, and the reputation of The Beyond Technque Residency program, Bundanon Trust and Dance Integrated Australia reserve the right to terminate my residency at my own expense.
X. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct at the time of completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:
Should be Empty:

The Beyond Technique Residency #3 - Expression of Interest Application Form

I. Contact details:

II. Dance Experience:

III. Availability and Interest:

IV. Accommodation:

V. Dance Practice:

VI. Acceess Requirements:

VII. Financial Investment

VIII. Additional information

IX. Authorisation and Consent

X. Applicant's E-Signature