MONTSERRAT / ACRV RESIDENCY PROGRAM APPLICATION

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1 MONTSERRAT / ACRV RESIDENCY PROGRAM APPLICATION For the Academic Year, we will accept applications on a rolling basis. NAME PLEASE PRINT YOUR FULL NAME AS IT APPEARS ON YOUR PASSPORT OF BIRTH GENDER STREET CITY STATE ZIP LOCAL TELEPHONE CELL PHONE HOME ADDRESS STREET CITY STATE ZIP PERMANENT TELEPHONE ADDRESS MONTH FOR WHICH YOU ARE APPLYING April May June September October November Other FOR INTERNATIONAL STUDENTS ONLY NAME PLEASE PRINT YOUR NAME AS IT APPEARS ON YOUR PASSPORT COUNTRY OF CITIZENSHIP COUNTRY OF BIRTH US IMMIGRATION STATUS I CURRENTLY DO NOT HAVE A US VISA I CURRENTLY HAVE A US VISA # I MUST APPLY FOR AN F-1 VISA (F-1, H-1, GREEN CARD, ETC.) APPLICANT SIGNATURE I am certifying that the information I have submitted is complete and correct to the best of my knowledge.

2 MALLORCA, SPAIN WINTERSESSION PROGRAM 2016 DECEMBER 27, 2015 JANUARY 9, 2016 STATEMENT OF PURPOSE FORM 2 OF 6 In two or three paragraphs please describe any university or professional experience relevant to the residency and what you hope to gain during during the residency. SIGNATURE

3 RECOMMENDATION Note: 2 recommendations are required TO THE APPLICANT This form is to be completed by a person, other than a friend or family member, who is familiar with your artistic and/or academic work. For the convenience of your reference complete the top portion of this form yourself and provide your reference with a stamped and addressed envelope. APPLICANT S NAME I am applying to study in the Montserrat / ACRV Residency Program. Under the provisions of the Family Educational Rights and Privacy Act, I retain my right of access to information contained in this recommendation. I waive my right of access to information contained in this recommendation. SIGNATURE OF THE APPLICANT TO THE REFERENCE The applicant named above is applying for entry to the Montserrat / ACRV Residency Program. Residents are selected on the basis of the merit of their program proposal, capacity to do independent work, and ability to adapt to another culture and environment. Please provide your frank opinion of the applicant s qualifications. 1. For how long and in what capacity have you known the applicant? 2. Please assess the quality and level of the applicant s artistic and/or academic work describing strengths and weaknesses. 3. How would you rate the applicant s ability to adjust easily to new or changing situations or environments? Bear in mind that the Residency Program requires a high degree of maturity, self-motivation, and commitment. 4. Please describe how the applicant relates to others, including mentors and peers. 5. Please make any additional comments about the applicant s qualifications for participation in a residency program. 6. I strongly recommend this applicant for the residency program. I recommend this applicant, but have reservations as noted above. I do not recommend this applicant for the residency program. NAME OF REFERENCE INSTITUTION OR COMPANY POSITION OR TITLE TELEPHONE May we contact you if we have any questions about your recommendation? yes no SIGNATURE OF REFERENCE

4 RECOMMENDATION Note: 2 recommendations are required TO THE APPLICANT This form is to be completed by a person, other than a friend or family member, who is familiar with your artistic and/or academic work. For the convenience of your reference complete the top portion of this form yourself and provide your reference with a stamped and addressed envelope. APPLICANT S NAME I am applying to study in the Montserrat / ACRV Residency Program. Under the provisions of the Family Educational Rights and Privacy Act, I retain my right of access to information contained in this recommendation. I waive my right of access to information contained in this recommendation. SIGNATURE OF THE APPLICANT TO THE REFERENCE The applicant named above is applying for entry to the Montserrat / ACRV Residency Program. Residents are selected on the basis of the merit of their program proposal, capacity to do independent work, and ability to adapt to another culture and environment. Please provide your frank opinion of the applicant s qualifications. 1. For how long and in what capacity have you known the applicant? 2. Please assess the quality and level of the applicant s artistic and/or academic work describing strengths and weaknesses. 3. How would you rate the applicant s ability to adjust easily to new or changing situations or environments? Bear in mind that the Residency Program requires a high degree of maturity, self-motivation, and commitment. 4. Please describe how the applicant relates to others, including mentors and peers. 5. Please make any additional comments about the applicant s qualifications for participation in a residency program. 6. I strongly recommend this applicant for the residency program. I recommend this applicant, but have reservations as noted above. I do not recommend this applicant for the residency program. NAME OF REFERENCE INSTITUTION OR COMPANY POSITION OR TITLE TELEPHONE May we contact you if we have any questions about your recommendation? yes no SIGNATURE OF REFERENCE

5 Montserrat College of Art Artist in Residence Program, Viterbo Italy Travel Waiver and Release Name: I hereby agree to the following: 1. Acknowledgment and Acceptance of Risk. I recognize that participation in all of Montserrat College of Art s (hereafter the College ) is voluntary and that there are certain inherent risks that participants voluntarily assume. I understand and agree that neither the College, nor it s partner The Cultural Association of Rosa Venerini (here after ACRV ), nor agents, officers, or employees of either the College or ACRV, assume any responsibility for damages to or loss of my property, personal illness or injury, or death to me while I participate in any program. By voluntarily participating, I freely assume any risk associated with or arising out of my participation in this program. 2. Insurance. I understand and agree that it is my responsibility to ascertain whether I have adequate health and accident coverage and to procure any other insurance coverage as I may deem necessary. 3. Waiver, Release, Indemnification and Hold Harmless. I do hereby forever and absolutely waive and release any and all claims against the College, ACRV, agents, officers or employees of either the College or ACRV arising out of or relating to my participation in any College program, including but not limited to, claims for any injury, loss, damage or accident including motor vehicle, animal bites or injuries arising from animals, weather, sickness, and acts of terrorism. I also agree to defend, indemnify and hold harmless the College, its agents, officers or employees of the College or ACRV from any and all liability, claims, lawsuits, judgements, losses, damages and expenses, including attorneys fees, arising out of any financial obligations or liabilities that I may personally incur or any damage or injury to the person or property of others that I may cause, while participation in any College program. 4. Personal Possessions. I understand that the College, nor ACRV nor agents, officers, or employees of the College or ACRV will not be liable or responsible for any of my personal property, or any personal proerty delivered to or left at ACRV. I also acknowledge that the College and ACRV are not in anyway responsible for protection, care, or insurance coverage for my tools, work in progress, or works of art in the event of damage or destruction anywhere on site, including studio work space, gallery or living quarters, or auxiliary spaces of ACRV. I further recognize that any items left at ACRV beyond 15 days become the property of the College and may be destroyed.

6 5. Local Laws and Prohibition of Illegal Drugs. I understand and agree that breaches of the local law will be referred to and handled by the appropriate law enforcement authorities. I agree that the use of illegal drugs in any form, as governed by the laws of the Italian Government and local authorities, will not be tolerated and will be grounds for immediate expulsion. 6. Medical Treatment. In the event that I suffer any injury or illness while participation in a College program, it is my responsibility to arrange for and pay for medical treatment. I further agree to assume any and all risks associated with or arising from any such medical treatment and agree to waive any and all claims which I might assert against the College, ACRV, agents, officers or employees of the College or ACRV for such medical treatment. 7. Security Deposits, Refunds, and Withdrawals. I agree to provide a valid credit card as a security deposit for damage to equipment or facilities, lost keys and unpaid invoices. I authorize the College to charge this card for any valid invoices thirty days or more overdue. All payments, including payments towards tuition and fees, are non refundable. I understand that if I voluntarily withdraw from the program, or if I am expelled from the program, I am not entitled to a refund in any amount. I understand that the College is not responsible in anyway for moneys spent towards travel arrangements or material expenses. 8. Cancellation. The College reserves the right to cancel the program at anytime. In the event the program is cancelled by the College, a full tuition refund will be issued. The College is not responsible for travel or other related expenses incurred by me, the participant, in preparation of participation. 9. Severability. I agree that, should any provision or aspect of this Agreement be found to be unenforceable, that all remaining provisions of the agreement remain in full force and effect. 10. Governing Law. I agree that if there is any dispute concerning my participation in the program or the interpretations of this Agreement, any such disagreement shall be determined in accordance with the laws of the United States of America and the COmmonwealth of Massachusetts. 11. Entire Agreement and Modification. The terms and conditions of this Waiver and Release of Liability represent my complete understanding of the parties hereto and with regard to my participation in any art program at the COllege and supersedes any previous or contemporaneous understandings I may have had with the College on this subject, whether written or oral, and cannot be changed or amended in any way without the written concurrence of both the College and me.

7 12. Independent Analysis and Binding Authority. I have carefully read this release and waiver of liability and fully understand its contents. I further acknowledge and agree that I have had an opportunity to consult with counsel of my choice prior to executing this release and waiver of liability. I acknowledge and agree that this release and waiver of liability shall be binding upon me, my survivors, heirs, successors and assigns. I am aware that this release and waiver of liability is a release of liability, including but not limited to liability for negligence, indemnification, and a hold harmless agreement, and I sign it of my own free will. This release and waiver of liability is in addition to and does not revoke or modify any other agreement or release which I may execute in connection with the College program. 13. Assurances and Consent. I have read all of the above information and consent to all of the foregoing provisions. Date: Participant signature Please Print the following information: Participant Name: Paticipant cell phone: (*participant must carry a cell phone while on the trip) Emergency Contact: Relationship: Emergency Contact Phone:

8 ARTIST / SCHOLAR IN RESIDENT PAYMENT AND REFUND AGREEMENT Program Cost Please see the Application & Registration Procedure information for details of program costs for the current year. The program cost cannot be guaranteed for applications or payments received after airline tickets have been purchased, if Montserrat is purchasing airline tickets for you. If and when a late application or payment follows a rise in airfares, the student will be responsible for the total increased fare. Payment Schedule (See the Application & Registration Procedure information for specific deadlines for payments.) To help ensure the quality and viability of the travel programs, the timely commitment of funds is required for a number of reasons, including, but not limited to housing, reservation fees, etc. The ability to make and confirm such arrangements is dependent upon the timely receipt of payment from participants. All payments must be delivered or sent to the Academic Affairs Office at Montserrat College of Art, 23 Essex Street, Beverly, MA, 01915, to arrive before or on the date stated in the Application and Registration Procedure and must specify the destination country of the study-travel program to ensure correct application of the payment. Checks must be made payable to Montserrat College of Art, and must indicate on the memo line of the check the destination country name. PAYMENT #1 APPLICATION FEE: $75 (non-refundable) payable to Montserrat College of Art at the time the application is submitted. This non-refundable application fee will be applied to the cost of the program. PAYMENT #2 (DUE AT LEAST 30 DAYS BEFORE THE START OF THE PROGRAM) 100% of program fee, payable to Montserrat College of Art. PLEASE BE ADVISED THAT a $75 late fee is charged for each late payment. If payment is not received in full by the deadline for that payment, the college reserves the right to withdraw the student s application. Refund Policy (Note: The word student as used here refers to all participants in the study-travel program [other than program faculty and staff], whether or not the individual is taking courses and/or taking courses for credit.)

9 Montserrat College of Art Artist / Scholar in Residence Program Payment and Refund Policy Page 2 of 2 Should the college cancel the program for any reason, all payments received by the college for that program will be refunded; checks that have not been deposited will be returned. Once purchased, there will be no refunds from Montserrat for the value of the airline ticket. We recommend that participants purchase travel insurance. If a participant withdraws from the program prior to the purchase of airline tickets, as yet uncommitted funds will be refunded to the student, less the $75 application fee. If a participant withdraws from the program for any reason (*see exception below) after airline tickets have been purchased, no refunds will be given. *If a participant withdraws from the program at any time as a result of personal medical incapacity, satisfactory documentation from a medical professional will be required for the refund of any as yet unspent funds, less the $75 application fee. In order to participate in the Artist / Scholar Residency program, a participant s charges must be paid in full, all funds received by the college, and the account cleared by the Bursar s Office by the date established for the particular program. This includes late fees. If payment is not received in full by the established date, the college reserves the right to withdraw the participant s application and there will be no refunds issued. The college reserves the right to cancel a program in consideration of the best interests of the travelers. Should the program be cancelled because of circumstances outside the college s control, including disruptions resulting from weather, labor actions, hostilities in the region, natural disasters, health concerns, or other uncontrollable events or circumstances, refunds will be made of all funds received at that point, less the $75 non-refundable application fee. If the student s application is rejected by the college, $50 of the application fee will be refunded. I have read this document, which states the payment obligations and refund policy for participants in the Montserrat College of Art travel programs, and I agree to abide by them. Participant s name (please print) Participant s signature Date Notary signature, date & seal

Travelearn Participant Form

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