Cape & Islands Workforce Investment Board School to
Careers Partnership and Heritage Museums and Gardens
ART INTERNSHIP - APPLICATION FORM 2013
Part I. Applicant Background Information
Student Name_____________________________________________________________
Last
First
Middle
Home Address_____________________________________________________________
Street #
Street Name
Apt. /P.O. Box #
Town________________________ State__________ Zip Code_________________
Home Phone #_____ - __________
Sex: Female Male Birth ____/_____/_____
Cell Phone #_____________________
E-mail address ____________________________
High School you attend______________________________Current Grade__________
Who referred you to this program?_______________________________________________
Please list any extracurricular activities that you are currently involved in and hobbies / interests that you
have: _________________________________________________________________________
______________________________________________________________________________
Do you have any responsibilities or obligations that could interfere with your ability to commit time after
school for this 8 week program? (I.e. sports, activities, family / child care)
Yes
No
If yes, please explain: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLEASE CHECK UP TO THREE CREATIVE INTEREST AREAS
Visual Arts:
 Painting
 Drawing
 Photography
 Sculpture
 Mixed Media
 Ceramics
 Fiber Arts
 Woodworking
 Digital Media
 Cartooning
 Computer Animation
 Graphic Design
 Filmmaking
Architecture:
 Landscape Architecture
Music:
 Voice
 Instrumental
 Conducting
 Composing
Theater:
 Acting
 Production
 Set Design
 Costume Design
Writing:
 Poetry
 Fiction
 Journalism
Culinary Arts:
 Pastry Chef
 Arts Administration
 Exhibit Design
 Other (Please describe) _______________________________
Please list any relevant courses that could help us determine your internship placement:
_____________________________________________________________________________________
_____________________________________________________________________________________
Part II. Past Work Experience
In the past two years, have you had a job, internship or voluntary position?
Yes
No
Part III. Applicant Essay - Outline your expectations for your Art Internship. Include information about
the medium you prefer and why.
(Please write clearly and legibly and use another sheet of paper if necessary.)
Part IV. Parent/Guardian Information (to be completed by parent/guardian)
Name______________________________
Daytime Phone # (_____) _____ - _______
My son/daughter/dependent has my permission to participate in the ArtWorks program.
________________________________________________________
Parent / Guardian Signature
_______________
Date
Please forward application to: Amanda Meyer, ArtWorks Program, Heritage Museums and
Gardens, 67 Grove Street, Sandwich, MA 02563.
The following is provided for your review and signature:
I give permission for my son/daughter/dependent’s name, image, and/or student work products to be
utilized in various forms of media including: newsletters, CIWIB or Heritage Museums and Gardens web
sites (images only), CIWIB, ArtWorks or Heritage Museums and Gardens print and video productions,
newspapers, magazines, or television), and future types of media for the duration of his/her enrollment in
the ArtWorks Program.
Please indicate whether you approve or disapprove, and sign below:
______________________________________
Name of Student
_______________
Date
I Approve/Disapprove (Circle one choice)
__________________________________________________
Signature of parent/guardian, or student if 18 years or older
This form is applicable for the duration on your child’s attendance at this school and will remain
permanently in the student’s file.
You may review and update this form at any time.
Cape & Islands Workforce Investment Board School to Career
Partnership and Heritage Museums and Gardens
STUDENT RECOMMENDATION FORM ARTWORKS INTERNSHIP 2013
(To be completed by a teacher, guidance counselor or a caring adult other than a relative)
Name of Student__________________________ School_____________________________
Please describe your relationship with applicant and why you believe he/she would be a good candidate for
admission into the ArtWorks Program.
________________________________________________________________
Signature
Date
Please forward recommendation to: Amanda Meyer, ArtWorks Program, Heritage Museums and
Gardens, 67 Grove Street, Sandwich, MA 02563.