Chinquapin Center for the Arts

Chinquapin Center for the Arts

 Mail-in: Application for Residency  

Please Type or Print Clearly and Circle Responses


Date: ___/___/____                                                Deadlines: January 1st & June 1st


Full Name:

 ____________________________________________________________________


Address______________________________________________________________


City _______________________ State/Country __________________ Zip_________


Phone (Home) _____________    Work/Cell:______________


Email: ____________________   Web site:__________________________________


Chinquapin Alum?  Yes   No          Last Applied in What Year? ____________


Artistic Discipline – Apply for only one category per deadline.


Poetry  . Fiction  . Nonfiction  . Play/Screenwriting  .  Musical Composition . 

Sculpture . Visual Art:  Toxics and/or Power Tools (circle if you will use one or both) 


Other ___________________________________________________________


Project Goal: [Basic] [If futher information is required, Please attach a separate page]

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


How can a CCA retreat support your efforts to reach this Goal? [Basic]

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

  

Preferred Residency Dates (If you are accepted, exact dates will be discussed. ______________________________________________________________________


Months Available (circle all that apply)

(June Deadline)   January   February   March   April   May   June

(January Deadline)   July   August   September  October  


Number of Weeks Requested: Available Anytime:  Yes    No


1st Choice:    2    4    6    8 ~  2nd Choice:   2    4    6    8  ~ Dates NOT Available


Gender:  M  F     Age:   20-35   36-45   46-55   56-65   66+


Household Income:  less than $25,000     $25-40,000      $41-60,000     $61,000+


Professional References Contact Information-1: Name / Email / Telephone

______________________________________________________________________


Professional References Contact Information-2: Name / Email / Telephone

______________________________________________________________________



Signature:  ________________________________                      Date: _____________