Accessible Application Form - Canada Council for the Arts

Cultivate: Professional Development Grants
The information that you provide on the first two pages will not be submitted to the assessment committee.
IDENTIFICATION OF APPLICANT
Name of applicant (your full legal name):
Mrs.
Miss
Ms.
Mr. Year of birth
I self-identify as a person who is Deaf, has a disability and/or is living with a mental illness.
Last name
Permanent address:
First and middle names
Mailing address (if different from permanent address):
Street address and apartment or suite number
Street address and apartment or suite number
City
City
Province or territory
Telephone (residence)
Postal code
Telephone (business)
Email
Province or territory
Telephone (residence)
Postal code
Telephone (business)
Website
DECLARATION
I permit the Canada Council for the Arts to include my name, address and email on its mailing list:
(This information will be used for Canada Council business only, including surveys.)
Yes
I prefer to communicate with the Canada Council in:
English
French
ASL
No
LSQ
To be eligible for consideration, you must sign below to confirm your agreement with all of the following
statements:
• I am a Canadian citizen or have permanent resident status, as defined by Citizenship and Immigration Canada.
• I have carefully read the eligibility criteria for this program, which are described in the application guidelines,
and I meet these criteria.
• I understand that I may apply for one grant from the Cultivate: Professional Development Grants program and
one Canada Council travel grant program per year.
• I understand that I am not eligible to apply to this program until all my overdue final reports for Canada
Council grants have been submitted and approved.
• I accept the conditions of this program and agree to abide by the Canada Council’s decision.
• I am aware that the Canada Council for the Arts is subject to the Access to Information Act and Privacy Act, as
described in the application guidelines.
I confirm that the statements in my application are complete and accurate, to the best of my knowledge.
Signature (an original signature is required)
Date
Personal information collected on this form will be stored in the personal information bank for the appropriate program.
PROTECTED WHEN COMPLETED/ EQFO8E 03-15
NAME OF APPLICANT:
Cultivate: Professional Development Grants / ii
ACCESS SUPPORT (if this applies)
Applicants to this program may apply for additional funds to cover expenses for disability-related supports and
services that they require to carry out the proposed eligible activities. Please see the Access Support section in the
program guidelines for details.
Total amount requested: $
As access support funds are separate from grant funds, do not include the total amount requested above within
your budget for the proposed activities.
DESCRIPTION
Amount Requested
Describe in detail the required services and supports and provide the cost breakdown.
For example: Workshop leaders will require sign language interpretation to communicate
with me during the workshop. I will need to hire two interpreters for 3 hours at $80 per
hour each and cover their travel expenses from a nearby town (two bus tickets at $75
each). Total amount: (3 x 80 x 2) + (75 x 2) = $630.
$630
Total amount requested
You must round your total amount requested to the nearest hundred dollars.
Personal information collected on this form will be stored in the personal information bank for the appropriate program.
PROTECTED WHEN COMPLETED
Cultivate: Professional Development Grants
The information that you provide from this point onward will be submitted to the assessment committee.
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The Canada Council for the Arts requires only one copy of your application form.
Do not bind your completed application form.
If you are completing your form on a computer, use the following format.
PART A1 – NAME AND LOCATION OF APPLICANT
Name of applicant (your full legal name):
Last name
First and middle names
City (permanent residence)
Province or territory
PART A2 – FIELD OF SPECIALIZATION AND DESCRIPTION OF GRANT REQUEST
Indicate if you are applying as an:
artist
OR
arts professional
Indicate the main artistic discipline(s) in which you work:
Dance
Inter-Arts
Media Arts
Music
Theatre
Visual Arts
Writing and Publishing
Indicate your specialization or role (e.g. actor, curator, composer, dancer, filmmaker, theatre director, writer, etc.):
Indicate the number of years you have been practicing as a professional artist or arts professional:
1-7 years
8-14 years
15 years or over
Indicate the amount you are requesting (rounded to the nearest hundred): $
(maximum of $2,500)
Project dates:
From
(day/month/year)
to
(day/month/year)
Note: your project dates must begin after you have submitted your application.
Provide a brief factual description of your project (in a maximum of 15 words):
For example: “To present my work at the DaDa International Festival in Bristol, UK.” or “To participate in an
intensive playwriting workshop at Other Voices, Mark Taper Forum”.
NAME OF APPLICANT:
Cultivate: Professional Development Grants / 2
PART B – PROJECT DESCRIPTION
On separate sheets of paper, provide a detailed description of your proposed professional development project
(maximum of two pages).
Include the following information in your project description:
•
•
•
•
an outline of the specific professional development activity(ies) that you will pursue, including timeline, location
and key people or organizations involved
how the project relates to your professional development goals and why you are pursuing the project at this time
how the project will advance your artistic practice or career
how the project might impact your peers, the artistic milieu in which you work and/or the Canadian Deaf arts,
disability arts and/or Mad arts sector.
PART C – SUPPORT DOCUMENTS
Attach the following supplementary information, as indicated:
Profile of applicant
Provide a brief description of your practice as an artist or arts professional, including the artistic discipline, genre
and/or technique in which you work, your role or specialization, your training and highlights of your professional
experience (maximum of one page).
Curriculum vitae or résumé
Submit a curriculum vitae or résumé outlining your experience in the arts (maximum of three pages). List your past
productions, performances, publications, exhibitions, projects, etc. Note: this document will be used to determine
your eligibility for this program (see Guidelines for details).
Biographies
If your project involves other key participants (such as a mentor, guru, Elder or private teacher), attach a paragraphlong biography for each of these individuals.
Travel Quote
If your project involves out-of-province or out-of-country travel, attach a quote from a travel agency or website
confirming the cost of economy air, train or bus fare for the period in which you will be travelling.
Information on host organization
If you are undertaking a professional development activity with a particular institution, organization, company or
festival, include published information on this host, such as a printed page from a website (maximum of one page).
Letter(s) of invitation or acceptance
If you are responding to an invitation to present your work or are participating in a professional development
program that involves an audition or acceptance process, submit a signed letter of invitation from the host
organization or event. A printout of an email invitation displaying the original headers is also acceptable. Letters
from presenters must confirm that a professional artist fee or equivalent in-kind contribution is being offered to you.
Letter of agreement from mentor
If your professional development project focuses on working with a particular mentor, guru or Elder, attach a letter
from that individual confirming their commitment to working with you and the terms of the mentorship.
Letters of recommendation
If you are a spoken word artist or storyteller who has not been paid in the past for your performances, attach two
letters from established spoken word artists or storytellers describing your role within the spoken word or
storytelling community.
Cultivate: Professional Development Grants / 3
NAME OF APPLICANT:
PART D – BUDGET
Provide a detailed list of expenses and revenues for your project activities. Costs must
be directly related to your proposed project. Only fill out the relevant budget lines. If
necessary, attach a separate page for additional budget details.
Original
Budget
(estimate)
Final
Budget (for
final report)
Subsistence for
weeks at $
/ week (maximum of $500/week)
Registration or course fees for workshops, conferences, master classes, etc.
Fees for mentor, guru or Elder
Travel costs (i.e. air, train or bus fare or car rental and gas) (specify):
$
$
$
$
$
$
$
$
Ground transportation
Accommodation and per diem costs for travel days (maximum of $200/day)
Specify number of days
Cost of producing portfolio materials
Ticket or admission fees to attend performances, exhibitions, etc. (maximum of $250)
Other expenses (specify):
$
$
$
$
$
$
$
$
$
$
Total expenses $
$
Expenses
Revenues
None Confirmed Pending
$
$
$
$
$
$
$
$
Total revenues $
$
Amount requested from the Canada Council for the Arts
If your total expenses exceed the amount requested from the Canada Council, please
specify other revenue source(s) for this program of activity (e.g. municipal/regional or
provincial/territorial grant, private donations, personal contribution, etc.):
Please ensure that total expenses equal total revenues.
NAME OF APPLICANT:
Cultivate: Professional Development Grants / 4
PART E – CHECKLIST
Use this checklist to confirm that you have completed all relevant sections of the form and have included all
required support material. Be sure to put your name on all items.
You must include the following items in the order shown below.
Identification of applicant
Declaration (an original signature is required)
Access support, if this applies
Part A1 – Name and location of applicant
Part A2 – Field of specialization and description of grant request
Part B – Project description (maximum of two pages)
Part C – Support documents
Profile of applicant (maximum of one page)
Curriculum vitae or résumé (maximum of three pages)
Biographies of key participants, if this applies
Travel quote, if this applies
Information on host organization, if this applies (maximum of one page)
Letter(s) of invitation or acceptance, if this applies
Letter of agreement from mentor, if this applies
Letters of recommendation for spoken word artists or storytellers, if this applies
Part D – Budget
Send your application:
By mail
Equity Office
Canada Council for the Arts
150 Elgin Street, P.O. Box 1047
Ottawa ON K1P 5V8
By email
[email protected]
_____________________________________________________________________________
Voluntary Self-Identification form (see the attached form)
You are encouraged to fill out the attached Voluntary Self-identification form to help the Canada Council
determine whether its programs and services are reaching a diverse and wide range of Canadian artists, as
intended. The Canada Council also welcomes any individual connected with the submission of a grant application
to complete the form. The information that you provide will not be used to assess the eligibility or the merit of
your application.