test form - Indiana Repertory Theatre

Name*

First Last

Home Phone #*

Student's Phone #

Student's Email*

Parent/Guardian or Teacher Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

OPTIONAL QUESTIONS. As a 501c3/not-for-profit organization, the IRT receives support from numerous institutions that desire a range of demographic information. Your response helps the IRT fulfill this funding requirement.

What is your age?

What gender do you identify as?

Which category best describes you? (Select all that apply)

American Indian or Alaska Native (Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc)

Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc)

Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc)

Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc)

Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc)

Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc)

White (Eg: German, Irish, English, Italian, Polish, French, etc)

Prefer Not to Say

Other

Name of School*

Grade Level*

Has your play ever been produced?*

What is the number of pages for your play?*

What is the title of your play?*

If this is a class assignment, what is the name of your teacher?

Teacher's Email

How did you hear about YPiP?*

Please identify in detail any IEPs, 504 plans, behavioral or physical access needs, or other information you want us to know.*

Please upload your YPiP submission*

Max. file size: 100 MB.

Please submit in .pdf file type only.

Email

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