Summer Writing & Film Application

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1 Summer Writing & Film Application 12 Highland Street Natick, MA Applicants to the Summer Writing and Film program at Walnut Hill School for the Arts are required to submit information so that we may better understand your background and preparation. Applicants must also submit a sample of work via Slideroom (walnuthillarts.slideroom.com) for review as part of the application process. You may submit a writing sample (2-4 pages) that includes poetry, fiction, screenwriting, or playwriting or a short sample film or video in any style that you have created (max. 5 minutes). Further details can be found at Please return this form and all other information directly to the Admission Office. Biographical Information First Middle Last Suffix Preferred First Name Permanent Address City/Town State/Province Home Telephone Gender: Female Male Country Zip/Postal Code Candidate s Cell Phone (if any) Candidate s Date of Birth Place of birth If not English, language spoken in your home Citizenship Information U.S. Citizen Dual U.S. Citizen; please specify other country of citizenship U.S. permanent resident visa; citizen of Alien registration number Other citizenship Country(ies) Will the candidate require a Form 1-20 and F-1 visa to enter the United States? Visa Type (if applicable) Yes No If you have dual citizenship, which citizenship should be listed on the Form I-20?

2 Optional Background Information Race/Ethnicity information is optional. Information you provide will NOT be used in a discriminatory manner. Please check all that apply. African American, Black African (country of family s origin ) Asian American (country of family s origin ) Asian, including Indian Subcontinent (country of family s origin ) Hispanic, Latino/a (country of family s origin ) Mexican American, Chicano/a Middle Eastern Native American, Alaska Native (date enrolled tribal affiliation ) Native Hawaiian, Pacific Islander Puerto Rican White or Caucasian (country of family s origin ) Other (please specify ) Prefer not to respond Educational Background Name of present school Current grade School Address Street City/Town State/Province Country Zip/Postal Code School Type (check all that apply): Public Private Parochial Charter Boarding Day Home School Prior Summer Program Information Have you ever applied to a summer program at Walnut Hill School for the Arts prior to this year? Yes No Have you ever attended to a summer program at Walnut Hill School for the Arts? Yes No If you have participated in previous extracurricular workshops, intensives, or summer programs including Walnut Hill, please list them with the dates attended, courses studied, and teachers below:

3 Family Information (Household 1) Parents are listed according to the household in which they live. If you have two parents living in the same household, please record their information in the parent sections under Household 1. If you have two parents living in separate households, record one parent s information in the first section of Household 1 and the other parent s information in the first section of Household 2. Parents Marital status (relative to each other): Married Single Separated Divorced Widowed Household 1 Information (Household 1 is the candidate s primary place of residence.) Permanent Address City/Town State/Province Country Zip/Postal Code Home Telephone Household 1 Parent/Guardian Parent/Guardian Type: Father Mother Guardian Living Deceased Household 1 Parent/Guardian Parent/Guardian Type: Father Mother Partner Living Deceased Unknown Stepfather Stepmother Guardian

4 Family Information (Household 2) Household 2 Information Permanent Address City/Town State/Province Country Zip/Postal Code Home Telephone Household 2 Parent/Guardian Parent/Guardian Type: Father Mother Guardian Living Deceased Household 2 Parent/Guardian Parent/Guardian Type: Father Mother Partner Living Deceased Unknown Stepfather Stepmother Guardian

5 Candidate Statement What role does writing and/or film play in your life? What do you hope to gain from your experience at Walnut Hill?

6 Additional Information / Explanation If you would like to provide any additional information that was not specifically requested or did not fit in the spaces provided, you may use the space below. Signatures In consideration of the undertaking by Admission Office at Walnut Hill School for the Arts, the undersigned agree that the information furnished on the final application forms, together with all information and materials of any kind received by the Admission Office from any source, or prepared by anyone at its request, shall be completely confidential and shall not be disclosed to anyone, including the candidate and his/her family, except that the director may, for official purposes at his/her discretion, disclose any part or all thereof to such person or persons as he/she deems advisable. Candidate Confirmation Signature Date Parent/Guardian Confirmation Signature Date Parent/Guardian Confirmation Signature Date Walnut Hill School for the Arts adheres to a long-standing policy of admitting students of any race, color, religious belief, gender, protected sexual orientation, nationality, or ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the School. Walnut Hill does not discriminate on the basis of race, color, religious belief, gender, protected sexual orientation, nationality, or ethnic origin in the administration of its educational policies, admission policies, scholarship programs, and other school program.

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