EmailMe Form - CREATIVE LIBERATION 2018 APPLICATION

Name *

First Last

Phone

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International Phone

Preferred Email *

Confirm Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Personal Pronoun Preference:

Other

Date of Birth:

Month/day/year (ex. xx/xx/xxxx)

How did you learn about our program?

Please let us know who referred you to us or if you found us online or in print media...

GETTING TO KNOW YOU!

When answering these questions, we know that you cannot tell us your whole story. Please send no more than one page and no less than a paragraph in response to each question. Thank you.

1. INTENTION:

Please share a brief intention that you are setting for this program.

2. WHAT IS CALLING YOU TO THIS PROGRAM?

Please share any previous experience with Melissa. Additionally, please describe your dance, somatic, or expressive arts background or training, include artistic skills, preferred modalities. Please be specific. We want to know about your skills and your gifts. If you have theatre training in lighting, set, tech, or anything like that, please also include that information in your answer.

3. BACKGROUND:

Please share anything relevant that would help us understand your unique call to creatively work in the areas of inclusion, liberation, justice, peace-making. What are the social and environmental questions living in you? What activism are you already engaged in? What are specific challenges you and/or your family/ community are facing in these areas?

4. WHAT IS BURNING IN YOUR HEART?

If you could help transform one social and/or environmental condition on this planet, what would that be? You may be involved in this work already, or you may not be as of yet. Essentially, what is a personal or collective challenge calling for your attention?

5. SPECIAL NEEDS OR REQUESTS:

Is there anything critical that you would like us to know about you? Challenges? Current life changes? Personal needs?

MEDICAL INFORMATION:

1. Please share any medical issues that could impact your participation in our program. (physical, psychological, other, including allergies)

2. Are you currently taking any medication? If so, please list and/or describe.

3. Are you pregnant?

YES

NO

4. Please provide any additional personal or medical information that will help us support you during this short but deep moving journey.

EMERGENCY CONTACT NAME: *

First Last

EMERGENCY CONTACT EMAIL: *

EMERGENCY CONTACT PHONE: *

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