School or site:

Principal:

Street Address:

City:

Zip Code:

Contact Telephone Number:

Contact Email Address:

In-school Coordinator:

TOTAL Student Population:

AIE Program Option Desired

Residency:

Number of Weeks:

Other Information:

Residency Cost: (Mileage and supplies are calculated at the time of residency)

Please select both a first & second choice of artists from our Roster:

1st Choice:

2nd Choice:

Preferred start date for this program:

Will the Artist require a Home Stay (Rural Locations or out-of-area artist)?
Yes No

What are your goals for this AIE art project?

Describe the groups that will meet with the artist. (Please check the artist description page to be aware of the number of students various projects can accommodate.)

Describe the working space and facilities available for the artist's use during the program:

How will you continue arts activities after the artist has completed the residency? How will those activities be incorporated into the curriculum?

Where will you publicize the AIE project that will take place at your site? (Please be sure to credit Umpqua Valley Arts Association, Oregon Arts Commission and the National Endowment for the Arts for funding assistance.)

By submitting this form, a statement of awareness in regards to requirements provided by the State of Oregon is agreed that teachers are to remain with their students at all times while Artists in Residence are engaged in projects as guests in their classroom.