1. CONTACT INFORMATION

Name of Peformer / Non Profit:

Contact Name:

Address:

City: State: Zip:

Tel: Cell: Fax:

Email: Alternate Email:

2. PERFORMER / ORGANIZATION
INFORMATION

Please check all that apply, or category that best describes your talent or organization:

Juggling Clown Dance Puppetry Magic
Storytelling Music Mime Theatre Non Profit
Arts & Crafts Artist (painting) Artist (Jewelry / Hand Made Art)

Other:

Please descirbe in detail your talent, organization and/or activity proposed, performance, and set up and any materials or supplies that will be used. Indicate how many performances or individuals will be present.

3. PERFORMANCE AVAILABILITY

Months Available:

Shifts Available:

4. PERFORMER BIOGRAPHY

Have you included a CD, video or pictures of yourself or organization set up? YES NO

Do you have a promotional link or website? YES NO

If yes, please provide link here:

I am inluding a photo for promotional use should I be chosen as a participant in the series.

5. PERFORMER REFERENCES

Please indicate references and phone numbers we may contact regarding your application.

Name: Business Name: Phone

Name: Business Name: Phone

Please list any other local events you have participated in of significance.

Event Name: Date of Participation:

Event Name: Date of Participation:

7. RELEASE & HOLD HARMLESS AGREEMENT: REQUIRED

I give permission to the Southern Arizona Arts & Cultural Alliance and General Growth Properties / Park Place Mall (referred to as the “Organization”) to use (including but not limited to taking photographs and making audio recordings or videos), without charge and without reservation, all or a portion of my story including my likeness and my voice in promoting this Organization. I acknowledge that editorial changes may be made as deemed suitable by the Organization. Whether or not changes are made, I waive any rights of action I may have and release the Organization from any and all claims I may have arising from the use, publication, and changes in the content, including any rights to sue for defamation or violation of rights or privacy or rights of privacy. (Must be signed by all performers in group and all performers and/or organization)

Please Accept Release & Hold Harmless Agreement by
typing your name, date, and Business ID#, Tax ID#, Non Profit ID#
in the boxes below.

Type your name here to Accept Agreement:

Name

Date:

Business ID#, Tax ID#, Non Profit ID#: