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Pour Your ART Out Workshop Sampler
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Application
 
I am applying to the Pour Your ART Out Workshop.
I have read the workshop description and meet the stated criteria.
I am applying to The Common Ground Project.
I have read the workshop description and meet the stated criteria.
 
Last Name
First Name
Nick Name
Middle Initial
Street Address
Apt. #
City
State
 Zip
-
Home Phone (10 digits no hyphens)
Cell Phone (10 digits no hyphens)
E-Mail
Retype E-Mail
  
Social Security # (optional)
(9 digits no hyphens)
 Gender
Male Female
Birthdate (mm/dd/yyyy)
/ /
Name of Emergency Contact
Relation
 Emergency Phone 
(10 digits no hyphens)
Do you plan to take a vacation in the near future?
Yes  No Unsure
When?
How will you get to the workshop?
Your Car Other Driver Public Transportation
Bike Walk Other
How did you hear about Arts On the Block?
School Teacher/
Official		 Newspaper Article Newspaper Ad
           
Friend/
Acquaintance		 Career Center Parent/Relative
           
Website Poster/Brochure Other
   
Do you have any physical condition which might limit your ability to perform the job for which you are applying?
Yes  No
If yes, please explain
Education
School Name (last attended):

Other
Current Year (if still in school):
High School:
9th Grade  10th Grade  11th Grade  12th Grade 
College:
1st Year  2nd Year  3rd Year  4th Year 
   
Most Recent Grade Point Average  # of Absences  # of Tardies 
Not In School  
If not in school, what was the highest grade completed
Will you attend school this summer?
Yes  No
Did you make the honor roll or dean's list?
Yes  No
Are you taking any honor's classes or involved in any advanced programs (please specify)?
In what school activities do you participate? Please specify including position or rank if appropriate. Example: Future business leaders of America - President ?
In what non-school club/activities do you participate? Please specify including position or rank if appropriate. Example: Montgomery county recreational basketball league - Team Captain?
Please list all honors and awards you have received (academic, artistic, athletic, attendance, etc):
Work Experience
Please list up to three (3) previous work experiences, both paid and volunteer
Work Experience 1
 
Name of Organization
Your Position or Title
Address
City State Zip
Name of Supervisor
First and Last
Phone (10 digits, no hyphens)
Start Date  End Date
Paid  Volunteer 
WORK EXPERIENCE 2
 
Name of Organization
Your Position or Title
Address
City State Zip
Name of Supervisor
First and Last
Phone (10 digits, no hyphens)
Start Date  End Date
Paid  Volunteer 
WORK EXPERIENCE 3
 
Name of Organization
Your Position or Title
Address
City State Zip
Name of Supervisor
First and Last
Phone (10 digits, no hyphens)
Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)
Paid  Volunteer 
Work Skills
Office Skills: 
(please check all that apply)

Word Processing
(Words/Minute)
Copy Machine
Adding Machine
Fax Machine
Cash Register
Computer/Technical: 
Rank yourself using the following Scale:
0= No Skills  1=Beginner 2=Intermediate  3=Advanced
  
Rating
Windows
Macintosh
Photoshop
Microsoft Word
Microsoft Excel
Microsoft Access
Internet Browsing
Web Page Design
Networking
Hardware
Other
(Please Specify)
  
Interests
Choose 5 job fields you would consider for employment (in order of preference)
  
Interest # 1
Interest # 2
Interest # 3
Interest # 4
Interest # 5
Other
  
Employment Goals
  
Please State Your Employment Goals
Describe the area(s) of work and the environment that you would like to work in. For example, shooting photographs for a magazine or newspaper, dancing with a major company, etc.
Terms
  
PLEASE READ
I hereby state all of the above and attached information is true and correct to the best of my knowledge. Misrepresentation or omission of material facts is cause for termination of placement efforts.

Typing your name below acts as a signature:  

Youth Signature