Artist Name *

First Name

Last Name

Artist Date of Birth *

(must be between the ages of 15-18 during the time of the program.)

MM

DD

YYYY

Artist Phone Number *

(###)

###

####

Artist Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Artist race/ethnicity - please check all that apply *

American Indian/ Alaska Native

Asian

Black/African-American

Native American

White/Caucasian

Native Hawaiian/Pacific Islander

Hispanic or Latinx

Other

Parent/Guardian Name *

First Name

Last Name