Apply to be a Member Artist

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender *

Male

Female

Non Binary

Race/Ethnicity

Creative Clay is committed to promoting diversity in all of its programming. Some grant funders require this data collection. Please select all that are appropriate or choose not to respond.

Black/African American/African

Hispanic/Latino/Latina/Latinx

White/Caucasian/European

Asian American/Asian/Pacific Islanders

Native American/American Indian/Indigenous

Multi-Racial/Multi-Ethnic (2+ races/ethnicities)

I decline to state

Phone Number *

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Support Coordinator

First Name

Last Name

WSC Phone

(###)

###

####

Photo Release

I Allow Photographs Of My Child To Be Used For Public Relations And Archival Purposes

Yes

No

Emergency Contact

First Name

Last Name

Emergency Phone

(###)

###

####

Check all that apply:

I am concerned about my eating habits

I am concerned about my weight

I am unable to control my behavior and/or thoughts

I am easily moved to tears

I am easily distracted

I am easily moved to anger and/or aggression

I am concerned about sexual issues

I am upset about a recent death

I am concerned about a recent break up or finding a significant other

I am depressed

I feel tired much of the time

I feel anxious and worried much of the time

I have obsessive/compulsive patterns

I have mood swings

I have a need to move around the room often

I have difficulty opening up and trusting people

I do not adjust well to new situations

Toileting *

I am able to toilet independently.

Yes

No

Please choose one:

I require adaptive equipment and have the equipment I need.

I do not require adaptive equipment.

Needs and Interests *

Communication:

Verbal

Hands/Gestures

Sign Language

Written word

Photos/Picture board

Cultural Interests:

Drawing/Illustration

Graphic Design

Animation

Photography

Ceramics

Sculpture

Mixed Media

Music

Theater

Dance

Writing

Videography

Hobbies:

Reading

Watching TV

Family Time

Going to the Movies

Fishing

Computer

Gardening

Walking

Running

Biking

Golf

Swimming

Tennis

Team Sports

Boating

Listening to Music

Shopping

Socializing

Sewing

Knitting/Crocheting

Church Activities

Playing Games

Cooking

Animal Care

Bowling

Beach

Visual Arts

Performing Arts

Billiards

Other

Employment *

I have a job.

I would like to have a job.

I am not interested in having a job.

I might be interested in having a job.

Today's Date:

MM

DD

YYYY

*

By checking this box, I understand that no aggressive behaviors will be tolerated at Creative Clay and can result in expulsion from the program.

Liability Release *

With regards to the applicant named above, I, the undersigned parent or legal guardian, do hereby release Creative Clay, Inc. or any person acting on its behalf from liability for any bodily injury sustained, or loss or damage of any personal items, while on the premises or participating in any activity sponsored by Creative Clay, Inc. Furthermore, the undersigned agrees that in the event that medical attention is needed due to accident or illness, Creative Clay, Inc., shall be permitted to seek medical services as it shall be deemed necessary and appropriate through EMS/911 and/or local hospitals.

By checking here, I agree to the above liability release.