LAND Gallery
Visiting Artist Application
Use this form to apply to work on a volunteer basis on a project with LAND artists. If your proposal is approved, we will provide the necessary materials for the project.
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What is your full name? *

 
What is your home address? *

 
Enter your phone number. *

 
Emergency Contact Information *

Please enter the name and phone number of an emergency contact.
 
Please tell us about yourself, your art, and why you are interested in working with LAND artists. *

 
Describe the project you are proposing to do with LAND artists. *

 
How many hours/days you would work with LAND artists? (Please note that art sessions are 1-2 hours each.) *

 
What days of the week you are available (Monday–Friday)?

 
Is there is a specific date you would like to begin?

 
How long will this project take to complete? *

Please provide the estimated duration of the project in days or hours.
 
Are there specific materials needed to complete the project?

If so, list the materials below.
 
Enter a link to your website or LinkedIn profile.

 
Have you ever been convicted of a misdemeanor or felony (not including minor traffic violations)? *

     
 
Please provide dates and details of the conviction. *

 
Have you ever been suspended or excluded from participating in the Medicaid or Medicare programs or are you currently under investigation by either program? *

     
 
Provide the Names, Addresses and Telephone Numbers of Two Personal References

 
Reference #1 *

Enter the name, address and phone number of your first reference.
 
Reference #2 *

Enter the name, address and phone number of your second reference.
 
By signing this proposal I declare that:

 
All statements made in this proposal and the attached resume are true.

 
I have read the VISITING ARTIST PROGRAM information contained in thisproposal and understand and agree to all of the terms of the project.

 
I understand that in the course of volunteering at LAND I may be dealing with confidential information and I agree to keep such information in the strictest confidence.

 
I give permission to LAND/THE LEAGUE TREATMENT CENTER to perform a background/criminal history check.

 
Signature *

By entering your name below and submitting this proposal, you agree to the terms and conditions above.
Thank you for your application. A member of our staff may contact you for more information if your proposal is accepted.
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