Prospective Performing Arts Student Form

Student's First Name:
Student's Last Name:
Parent's/Guardian's Name:
Address 1:
Address 2:
City, State, Zip:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Country:
Male / Female:	Male Female
Date of Birth	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
E-mail:
Telephone:
Current School:
Type of School	Public Private Parochial
Applying for Grade:	9th 10th 11th 12th PG
Applying for Academic Year of:	Jan 2007 Fall 2007 Fall 2008
Which performing arts are you active in?
Dance Music Theatre
DANCE BACKGROUND
In what disciplines do you have training (check all that apply)?
Ballet Musical Theatre Ethnic (Afro-Cuban, slaso, etc.) Jazz Tap	Pointe Production/Kick Line Hip Hop/Funk Modern Other
How many years of training?
In what type of setting?	Conservatory Performance Company Studio Afterschool Activity Other
Have you engaged in choreography work?	Yes No
MUSIC BACKGROUND
What is your primary instrument (including voice)?
Have you taken private lessons?	Yes No
If yes, for how many years?	0 1 2 3 4 5 6 7 8 9 10+
Number of hours you practice per week?	0 1 2 3 4 5 6 7 8 9 10+
What ensembles are you currently active in?
1 Auditioned? Chair
2 Auditioned? Chair
3 Auditioned? Chair
What are the two most recent pieces you learned?
1 Performed? Yes No
2 Performed? Yes No
Who is your primary teacher on this instrument/voice:
Teacher's Name:
School:
Telephone:
Email:
Other Interest: Music Composition Music History Music Theory
THEATRE BACKGROUND
What productions have you performed in and where?
Title Role Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Title Role Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Title Role Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Title Role Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Have you participated in community or regional theatre?	Yes No
Have you scheduled a campus visit at Cushing?	Yes No
If yes, what day?	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Have you received admission materials from Cushing?	Yes No