First Name *

Last Name *

Home Address

Post Code

Postal Address (if different to above)

Home Phone

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Email Address *

Date Of Birth ...

Medical Conditions

1. Name

1. Phone

1. Mobile

2. Name

2. Phone

2. Mobile

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What discipline are you applying under? i.e. Director/Designer etc

Why do you want to be part of the Associate Artists Program for 2013?

What are your strengths in your chosen discipline?

What weaknesses or areas of your practice do you want to work on?

Please outline your current commitments (University, School, Work etc)

Please list any shows, events, relevant classes or training

I agree that I am available for the periods listed in these pages and I agree to fully commit to the Schedule negotiated if I am selected to join the 2013 Chrysalis: Associate Artists Program Yes No

I grant permission to Canberra Youth Theatre to use still and moving images of me for the purposes of use in any CYT publication (all media, including web), exhibitions and CYT marketing and publicity Yes No

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