Fillable Teaching Institute in Museum Education (TIME) Application Form (School of the Art Institute of Chicago)

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Teaching Institute in Museum Education (TIME) Application Form (School of the Art Institute of Chicago)

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Teaching Institute in Museum Education (TIME) Application Form
SUMMER 2018
MI
Address Apartment
City
State Zip Code
Home Phone
Work Email Adress
Last Name
Mobile Phone
First ID # (If returning)
Date of Birth
Email Address
Gender: Male Female
School of the Art Institute of Chicago
Continuing Studies
36 South Wabash Avenue, suite 1201
Chicago, IL 60603
Email: cs@saic.edu
Phone: 312.629.6170 Fax: 312.629.6171
INFORMATION
Last Name First Relationship to student
Email Address
Phone
Type: Mobile Home Work
EMERGENCY CONTACT INFORMATION
High School City State Zip
EDUCATION
Museum Name Street Address City State
MUSEUM INFORMATION
TEACHING INSTITUTE IN MUSEUM EDUCATION (TIME)
Note: If there is a medical/health condition or disability that might require emergency assistance, or special need requiring regular classroom assistance, please please email cs@saic.edu
with details.
Museum’s geographic location Urban Suburban Rural
Estimated yearly museum attendance:
Estimated number of museum educators:
Number of years working at this institution:
Number of years working in museum education:
Note: Date of birth is required to obtain an SAIC login
for access to various web-based resources.
Undergraduate Degree Year Subject Institution City State
Graduate Degree Year Subject Institution City State
Professional Organizations and Memberships
Museum Phone
I have previously applied for TIME Yes No If yes, when?
TIME 2018: August 5-10-FREE
Application Deadline: May 11, 2018
Teaching Institute in Museum Education (TIME) Application Form
School of the Art Institute of Chicago
Continuing Studies
36 South Wabash Avenue, suite 1201
Chicago, IL 60603
Email: cs@saic.edu
Phone: 312.629.6170 Fax: 312.629.6171
CANCELLATION POLICY
TIME requires a significant investment – both by participants and Continuing Studies at the School of the Art Institute of Chicago. Though discouraged, cancellations
will be accepted two weeks prior to the start of the program. Cancellation requests must be submitted in writing to cs@ saic.edu and include the student’s name, ID
number, and session. Upon receipt, a review of applications will be done and a replacement identified if possible. Cancellation requests received less than two weeks
prior to the start of the program may result in a cancellation fee.
The information reported on this application is true and correct to the best of my knowledge. By signing, I confirm that I have read and understood the Cancellation
Policy, and and also read and agree to abide by the Student Rights and Responsibilities as stated at saic.edu/teacher.
Signature_______________________________________________________
Date________________________________
Complete applications must include the following:
Completed TIME Application Form (Including Photographic Consent Form & Special Groups Summer Housing Acknowledgment)
Statement of interest in attending the Teaching Institute in Museum Education – 300 word limit Current Resume/CV
Current Resume/CV
Please email this form and application materials to: saic-time@saic.edu
Questions? Phone: 312.629.6170
CAMPUS HOUSING
Housing is available in the SAIC residence hall free of charge. Residence hall check-in occurs on the session start date, Sunday, August 5, by 2:00 pm. Residents are required to check-out by
10:00 a.m. on Saturday, August 11.
Note: Participants that opt to reside on campus must submit a completed 2018 Special Groups Summer Housing Acknowledgement (included in this document) with their completed
Teaching Institute in Museum Education (TIME) Application Form.
Yes No
SUMMER 2018
ACKNOWLEDEGMENT + AGREEMENT
• The information reported on this application is true and correct to the best of my knowledge.
• I give SAIC permission to obtain emergency medical care, hospital, or clinic treatment for me. I hereby waive liability against SAIC for such care and for transportation provided to such
locations as deemed necessary by SAIC.
• I have read and agree to abide by the Rights and Responsibilities for ACE, APSI, AND TIME Students online at saic.edu/teacherprograms>Forms and Downloads.
By signing below, I agree to the above on behalf of myself.
Are you interested in reserving a room in the SAIC residence hall?
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signature
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PHOTOGRAPHIC!CONSENT!FORM!
I!hereby!gr an t !p er m is s io n !to !th e !S ch o o l!o f!t h e!A r t!In st itu te !o f!C h ic ag o !(“SA IC”)!and!its!agents!to!record!
photographs!or!other!images!or!likenesses!of!me!on!videotape,!audiotape,!film,!photograph!or!any!other!medium!
and!use,!reproduce,!modify,!distrib ute ,!and !pu blicly!ex hib it!such !reco rdin gs,!in!whole!or!in!part,!without!
restrictions!or!limitation s!for!an y!pu rp os e!tha t!SAIC !de em s!ap p rop riate !includin g !d iss ert at ion s ,!ad v e rtisin g ,!
publicity,!and!Internet!(SAIC!website)!purposes.!I!further!co n s en t !to !th e !u se !o f!my!name,!voice,!and!biographical!
material!in!connection!with!such!recordings.!
I!understa n d !th a t!a s !p ar t!o f!th e !P ro g ra m ,!I!may!crea te !o r!p a rtic ip a te !in !th e !cr ea tion!of!art!projects.!On!behalf!of!
myself,!I!grant!permission!to!SAIC!to!photograph!or!reproduce!in!any!medium!any!such!projects,!in!whole!or!in!
part,!without!restrictions!or!limitations,!for!any!purpose!that!SAIC!deems!appropriate!including!dissertations,!
advertising,!publicity,!and!Internet!(SAIC!website)!purposes.!
I!waive,!on !b e h a lf!o f!myself,!an y !righ t !to !in sp e c t!o r!a p p ro v e !th e !im a g e s!d e s crib e d !above!and!I!understand!that!the!
images!u se d !m a y !b e!d ist o rte d ,!blu rr ed ,!o r!a lte red .!I!a ls o !u nd e rs ta n d!t h at !p u blic a tion !o f!th e!images!is!w it h in!t h e!
sole!discretion!of!SAIC!and!that!they!may!not!be!used!at!all.!
On!behalf!of!myself,!I!waive,!release,!and!hold!harmless!SAIC!from!any!claims!related!to!the!images!describ ed !
above!or!the!exercise!of!the!rights!and!permissions!granted!herein,!including!claims!fo r!co mpensa tio n ,!cla ims!of!
defamation!or!any!claims!regarding!rights!of!privacy!or!publicity.!
Signature*of*student*
Print*name*
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signature
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2018 Special Groups Summer Housing
Acknowledgement
Policies
Teaching Institute in Museum Education residents are responsible for knowing and adhering to the Rights and
Responsibilities for ACE, APSI, and TIME. These rights and responsibilities, which are subject to change from time to time,
can be found at: saic.edu/teacherprograms > Forms and Downloads. Specific policies are listed below.
Alcohol
Residence hall policies concerning the consumption of alcohol comply with the Illinois State Liquor Law. If you are under 21
years of age, it is illegal in the State of Illinois for you to possess or consume any alcoholic beverage. Residents must adhere
to the following policies:
-Alcoholic beverages may not, under any circumstances be used by, possessed by, or distributed to any person under 21 years
of age.
-Open containers of alcohol are not permitted in any public/common areas of the residence hall.
-Multi-quart containers (kegs, etc), are not allowed in the residence halls.
Drugs
Federal and State laws prohibit the possession, manufacture, distribution and use of certain drugs, drug paraphernalia, and
narcotics. Any resident known to be possessing, using, abusing, manufacturing, or distributing illegal drugs or drug
paraphernalia may be expelled from the residence hall and/or SAIC, and may be referred to the appropriate authorities for
prosecution. This paragraph shall also apply to the abuse or misuse of any over-the- counter medication or prescription
medication.
Smoking & Fire Safety
In compliance with state and local laws, smoking is completely prohibited in all SAIC buildings, including residence halls
and classroom buildings. Residents are not permitted to smoke in residence hall rooms, classrooms, common areas, or
anywhere else in SAIC buildings. Hookahs are not allowed in the residence hall. Smoking is also prohibited within 15 feet of
the entrance to all SAIC buildings. To ensure that any potential risk of fire is eliminated, residents are not permitted to tamper
with fire safety equipment, burn candles, leave cooking unattended, and have open element appliances.
Windows
The Resident must not tamper with the window safety equipment (including but not limited to window screens and window
blocks) in the residence hall, nor allow any guest or visitor to tamper with the window safety equipment. Any issues
concerning the proper operation of window safety equipment and/or damage to screens or window safety equipment must be
immediately reported to Residence Life. Hanging items in the window or throwing objects from a window is strictly
prohibited. Residents may not place signs in or on their windows. Contact a Residence Life or Campus Security staff member
immediately if your window or screen is not secured.
Acknowledgement + Agreement
By signing below, I acknowledge that I have read and understand these policies and further agree that I shall abide by them
while living at SAIC. I further acknowledge and agree that, in the event that I violate any applicable law and/or the above
stated policies, SAIC may, in its sole discretion, impose sanctions against me, including but not limited to expulsion from the
residence hall.
Signature of Resident Date
Print Name
Resident Disclosure of Criminal Convictions
As part of your request for housing in a residence hall, the School of the Art Institute of Chicago (“SAIC”) requires you to
disclose information regarding any criminal convictions that you may have. Your answer must be truthful, accurate and
complete. Acceptance into SAIC housing is expressly conditioned upon SAIC’s review and acceptance, in its sole judgment,
of your criminal conviction disclosure. If you are not accepted, SAIC will notify you. If SAIC learns at any time that your
disclosure was not truthful, accurate or complete, SAIC may, in its sole judgment, revoke your housing in a SAIC residence
hall.
Indicate below by checking the appropriate box whether you have any instance in any state or country where you have plead
guilty or were found to be guilty by a judge or jury to charges that you committed a crime other than minor traffic offenses.
You are not required to disclose any arrest or criminal history record information ordered expunged, sealed or impounded
under applicable law or any conviction reversed on appeal.
If you checked “yes,” you must complete the Student Disclosure of Criminal Convictions and Consent to Obtain Additional
Information. This form can be found at http://www.saic.edu/life/housing under the section titled “How to apply for housing
FAQ.” If you checked “yes” above, you must submit this form immediately.
By signing below, you certify that this information regarding criminal convictions is truthful, accurate and complete and that
you understand and agree that you will notify SAIC immediately of any inaccuracies in, or corrections to, the information
you disclose here. You also certify that you understand and agree that you have a continuing duty to notify SAIC of any
criminal conviction during the time that you are living in SAIC’s residence halls.
Signature of Resident Date
Print Name
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Yes
No
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Teaching Institute in Museum Education (TIME) Application Form (School of the Art Institute of Chicago)

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Completed 26 August 2020

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