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* 1. Name

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* 2. Pronouns (ie: she/he/they/xe)

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* 3. Company

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Country

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* 9. Email Address

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* 10. Phone Number

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* 11. Birth Year

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* 12. How do you identify in terms of race/ethnicity? Please select all that apply.

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* 13. How do you identify in terms of gender?

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* 14. Website

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* 15. Social Media

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* 16. Has your artwork been exhibited? Are you represented by a gallery? If so, please include relevant contact information.

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* 17. Please include samples of your work in this Dropbox folder. It is important that you save and label your artwork with your first and last name. Sample #1

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* 18. Please include samples of your work in this Dropbox folder. It is important that you save and label your artwork with your first and last name. Sample #2

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* 19. Please include samples of your work in this Dropbox folder. It is important that you save and label your artwork with your first and last name. Sample #3

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* 20. What is your preferred artist medium? Select all that apply.

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* 21. How did you hear about Brushes with Cancer?

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* 22. If you heard about the program through a friend or family member, please let us know who referred you.

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* 23. Have you or a loved one been touched by cancer?


 

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* 24. Who has been touched by cancer?

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* 25. What reservations do you have about participating in Brushes with Cancer?

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* 26. I understand I am responsible for connecting with my Inspiration a minimum of 6 times over the course of our work together.

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* 27. Do you anticipate any barriers to participating in the program, such as ADA accommodation needs, financial concerns, language barriers, etc?

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* 28. What does your support system look like?

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* 29. What is your preferred method of communication?

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* 30. I believe I am emotionally prepared to hear stories of struggle and strength.

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* 31. I believe I am emotionally prepared to create a work of art reflective of an individual’s journey with cancer.

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* 32. I believe I am emotionally prepared to listen and reflect in discussions with my inspiration, but that I understand that am not responsible for providing formal support or counseling during my inspiration’s healing process.

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* 33. If chosen to participate in the program, you will be given at least 4 months to connect with your inspiration. Please tell us how you would spend that time.

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* 34. I understand that while this is meant to be a mutually rich experience, it’s important to be conscientious about what I share with my inspiration about my own personal struggles. I understand it is not my inspiration’s responsibility to provide support to me should I choose to share my own experiences with them.

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* 35. I understand that I alone am responsible for creating a unique work of art that will reflect the experience of my inspiration.

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* 36. Do you anticipate undergoing any major life changes or significant stressors which may overlap with the Brushes with Cancer Program timeframe that may or may not impact your participation in the program?

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* 37. As part of an ongoing effort to strengthen the impact of our programs, we may collect and analyze participant responses to program applications and evaluations. When analyzing responses, we are interested in trends in our data, rather than the responses of any particular person, and therefore responses will be de-identified for the purpose of data analysis. If you prefer that your responses not be included in data analyses, please check below. Please select Yes if you wish to include your de-identified responses and select No if you wish to not include your responses in future studies.

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* 38. I understand that although this is an opportunity for exposure, the connection with my inspiration and the sacredness of their story is the priority.  So I pledge to not disrespect these boundaries by introducing a sales element into the relationship.

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