First Name: * Middle Name: Last Name: * Date of Birth (MM/DD/YYYY): *
Grade: * 6
7
8
9
10
11
12 School Name: * How do you identify your gender? * How do you identify your race? * How do you identify your ethnicity? * Street Address Line 1: * Street Address Line 2: City: * State: *
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code: * Country:
Select Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia (Local Name: Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Icel And
India
Indonesia
Iran (Islamic Republic Of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Dem People'S Republic
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Dem Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Ant Illes
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint K Itts And Nevis
Saint Lucia
Saint Vincent, The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia , S Sandwich Is.
Spain
Sri Lanka
St. Helena
St. Pierre And Miquelon
Sudan
Suriname
Svalbard, Jan Mayen Islands
Sw Aziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Is.
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis And Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Home Phone Number: * Cell Phone Number: Student's Email Address: PARENT/GUARDIAN INFORMATION: Student Lives With: * Mother
Father
Both
OtherIf other, please state relationship to student: Mother/Guardian First Name: * Mother/Guardian Last Name: * Mother/Guardian Occupation: * Mother/Guardian Business Phone: Mother/Guardian Cell Phone: Father/Guardian First Name: Mother/Guardian Email Address: * Father/Guardian Last Name: Father/Guardian Occupation: Father/Guardian Cell Phone: Father/Guardian Business Phone: Father/Guardian Email Address: PLEASE ANSWER THE FOLLOWING QUESTIONS: How did you find out about Penumbra's Summer Institute? * Who were you referred by? * What experiences have you had with the performing arts? * Do you have specific goals for your time spent at Summer Institute? What would you like to accomplish during the four weeks? * Why do you think you would be a good candidate for the Summer Institute program? * Please list any extra- or co-curricular activities in which you have been involved including volunteer/service experiences. * ESSAY QUESTION
Please answer the following short essay questions:
In your own words, what does 'art for social change' mean? What kind of contribution would you like to make through your art? * SCHOLARSHIP INFORMATION Important Note: In order to be considered for a scholarship students must submit this information with their application.
Scholarships are awarded to eligible students on the basis of need and dedication to the performing arts. If you would like to be considered for a scholarship, please answer the following questions to the best of your ability.
How many people are in your household?
1
2
3
4
5
6
7
8
9
10
more than 10 What is your household's annual income? Do you feel an obligation to provide financial support for your family?
No
Yes Are you on the free and reduced lunch program at school for 2009-2010?
No
Yes In 2009-2010 did your family receive public assistance, disability, social security benefits or WIC?
No
Yes If yes, please explain: Are you or your parents (a) first generation immigrant(s) to the United States?
No
Yes Is there anything else you would like to share with us about your financial situation?