Intake Form (Theatre Without Borders)

All information uploaded on our intake form will be see only by freeDimensional staff and Distress Services case consultants and will remain entirely confidential.

Who is filling out this form? Are you: *

Artist at RiskNominatorFriend/Family

If you are Nominator, Friend or Family member filling out this application please indicate your name here:

Name of Applicant *

Date of birth *

Gender *

FemaleMaleOther

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email Address *

Contact phone number *

Contact phone number 2

Country(ies) of citizenship *

Current location *

Languages spoken *

YOU ARE APPLYING FOR WHICH OF THE FOLLOWING *

Creative Safe Haven (short-term long term residency)Creative Resistance Fund (small emergency grant)Services/ Resources

Services/ Resources Needed

PsychosocialLegalMedicalEmploymentEducationHousing/Food/ClothingProfessional DevelopmentCommunity Engagement

Other services or resources needed

Please indicate the level of urgency of your request *

LowOn-goingImmediate

Please state your reason for requesting freeDimensional's assistance and give a detailed account of your current situation. *

What is(are) your area(s) of work? Please describe your latest projects as they relate to your current situation. *

Are you facing persecution as a result of your work? (threats, attacks, harassment, arrests, socially marginalized, blacklisted, etc.) If possible, please give specific examples, with dates, locations, and key individuals involved. *

Is the persecution you are now facing related to aspects of your personal identity? (For example: race, class, ethnicity, gender, or sexual orientation.) If so, please explain. *

Have you been in touch with other organizations about your situation or sought other sources of support? If so, please tell us which ones and who your contact person there is. *

Are you member of any organization, academic institution or professional association? If so, please describe its mission or main focus of work, provide address, phone number, email, and name of the person accountable. *

Are you currently employed? If so, please provide your employer's contact information if relevant to your situation. *

For any additional information you which to provide please use the space below.

Instructions Please be sure to click “Submit” and wait until your browser finishes before going to another page. You may wish to print this page, or copy and paste your answers into an email to us, to ensure your submission is saved, in case it doesn’t go through. Please contact us at distress@freedimensional.org if you need any help getting this form submitted to us. Thank you! PLEASE NOTE: All cases all carefully vetted by freeDimensional staff and volunteer Distress Services case consultants. Due to the high volume of requests and varying levels of urgency, the average response time is three days to one week.

Intake Form (Theatre Without Borders)

Intake Form

APPLICANT INFORMATION

CASE INFORMATION

Verification

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