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. *

Yes
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 *

Prefix First Name Middle Name Last Name Suffix

Home Address : *

Street Address
Street Address Line 2
City	State / Territory
Post Code	Country

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

Area Code Phone Number
Telephone No. : *

Area Code Phone Number
Birthdate: *

Month Day Year
Do you require assistance filling out this form? *

Yes No
If you answered Yes, what is the full name of person filling out this form

Prefix First Name Middle Name Last Name Suffix
Relationship to applicant:
Mobile No. :

Area Code Phone Number
Telephone No. :

Area Code Phone 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)?

Yes No
If Yes, where?
Studying at a pre-tertiary / tertiary-level dance institution?

Yes No
If Yes, where?
A recent graduate?

Yes No
Course Attended / Attending:
Other:
Year of Graduation:
Working indpendently?

Yes No
Working with a company?

Yes No
Name of company:
Have you previously worked with Philip Channells ? *

Yes No
Have you previously worked with Lee-Anne Litton? *

Yes No
III. Availability and Interest:
I wish to attend The Beyond Technique Residency #3 *

Yes No
I am available between Sunday 1st - Sunday 8th November 2015 *

Yes No
I would like to attend only part of the residency

Yes No
Dates available:
I am interested in disability-inclusive dance practice *

Yes No
I am interested and available to volunteer throughout the week.

Yes No
IV. Accommodation:
I require single room accommodation (extra $100) *

Yes No
Comment:
I am happy to share twin accommodation with another artist *

Yes No
Comment:
I sleep with the light on

Yes No
I'm told I snore loudly

Yes No
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.

Yes No n/a
Family member, Friend or Colleague?
Support person's name

Prefix First Name Middle Name Last Name Suffix
E-mail
Phone Number

Area Code Phone Number
Participant in the project

Yes No
V. Dance Practice:
I am interested in developing: *

new solo work ensemble practice both
I am happy to work in Either group *

Yes No
Preference:
VI. Acceess Requirements:
Do you have a disability? *

Yes No
Comment:
Preferred method of contact *

Email Mobile / Text Telephone Other
If Other, comment:
I have access requirements? *

Yes No
Comment:
I have medical requirements? *

Yes No
Comment:
I have dietrary requirements? *

Yes No
Comment:
I need transport assistance to Bundanon Trust's Riversdale Property? *

Yes No
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. *

Yes No n/a
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 *

Yes
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

$1000.00 waged $900.00 concession
General / EOI received between Sat 26 September – 18 October 2015

$1100.00 waged $1000.00 concession
I would like to apply for a payment plan. *

Yes No
I agree to pay in full by 5pm Monday 26 October 2015 *

Yes No
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. *

Yes
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. *

Yes
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