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NAME OF APPLICANT (Please Print) ____________________________________________________________


Preferred title (circle one) Mr. Mrs. Miss Ms Other: ____________________


Name as it appears or will appear on your passport _________________________________________________


Mailing Address __________________________________________City ________________________________


Province__________ Postal Code______________________

Telephone (home) (_____)____________________________


E-mail Address _______________________________________________________________________


Birth Date __________________ Birthplace _________________________


Name preferred on nametag __________________________________


Passport Number __________________


Date Issued _________________ Place Issued _____________________ Expiration Date _________________


Citizenship _______________________


State of health

(Please indicate any special needs related to health concerns, i.e., medical conditions and/or medication, wheelchair, crutches, diabetic, allergies: food, medical or environmental, etc.) Use a separate sheet if needed:


_____________________________________________________________________________________________


_____________________________________________________________________________________________


^ Emergency Contact:

Name _____________­­­­­­­­­­­­­­­­__________________time of application__________________________________________________________________________________________________________________________________________


Telephone (home) (______)_________________________(business) (_______) __________________


^ Do you have prior travel experience? If yes, please indicate where, how long and when?


_____________________________________________________________________________________________


_____________________________________________________________________________________________


What is your native language? _____________________ Do you speak & understand English? Yes / No


_____________________________________________________________________________________________


^ Write a paragraph to describe your interest in the Summer School of Icon-Painting.


Do you have any experience in Icon-Painting:

None _______

One or a few icons _______

Painting icons all the time ______


Did you take part in the School of Icon-Painting? Where?


Did you take any theoretical courses connected with Eastern Christian theology, history or spirituality? Please write details?


Have you ever taken before any classes dedicated to iconography, theory of the icon or history of icon painting? If yes, give us a short description of them.


Have you read books about iconography, icon theory or history of icon painting?


Why do you want to take part in the School of Icon-Painting?


What are your expectations from the School of Icon-Painting?


Where did you get the information about Icon-Painting Summer School?


THE DEADLINE FOR APPLICATION IS: MAY, 14, 2012


More info at: http://www.os.ucu.edu.ua/en/ipss.html



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