IAM Student Application (2018) Thank you for your interest in the Institute for Advanced Media. By submitting this application, you are steps closer to making your goals a reality. If you have any questions, please contact Jennifer Worhle at email@example.com. 1 General2 Education3 Military4 Employment5 Accommodations6 Questions7 Submit General InformationName* First Last Email Address* Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you 18 years of age or older?*YesNoAre you a United States citizen?*YesNoGenderMaleFemaleTransgenderPrefer not to sayWhich of the following best represents your racial or ethnic heritage?Non-Hispanic White or Euro-AmericanBlack, Afro-Caribbean, or African AmericanLatino or Hispanic AmericanEast Asian or Asian AmericanSouth Asian or Indian AmericanMiddle Eastern or Arab AmericanNative American or Alaskan NativePrefer not to sayProgram InformationHow did you hear about this program?*ReferralInternetWord of mouthRadio or televisionOtherReferral Name First Last Which website did you find us on? Please specify where you found us.Are you a graduate of the IAM program?*YesNoIf you are a graduate, which class did you take?*Video Editing (VE)Video Production (VP)Graphic Arts and Digital Design (GADD)Project Management Skills for Life seminars (PMSLS)Documentary Storytelling (DS)Are you applying for a scholarship?*YesNoClass*Video Editing (VE)Video Production (VP)Graphic Arts and Digital Design (GADD)Project Management Skills for Life seminars (PMSLS)Documentary Storytelling (DS)N/ASemester*Spring 2019Fall 2019N/ALocation*HartfordNew Haven Save and continue later EducationHigh School*High School Address* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year Graduated (YYYY)*Date of Issue (MM/YYYY)*Have you received an equivalency diploma or GED?*YesNoPost-Secondary EducationPlease list all post-secondary institutions attended after high school.Post-Secondary InstitutionsNameCity, StateStart Date (MM/YYYY)End Date (MM/YYYY)Degree Earned Save and continue later Military Service Information (If Applicable)Military TypeActive/Reserve MilitaryVeteranMilitary SpouseMilitary CaregiverN/ALast or Current UnitBranchRank/Pay GradeSkill identifier/Title/MOSHave you ever deployed to Iraq or Afghanistan?*YesNoWere you injured while on active duty?*YesNoAre you eligible for VA benefits?*YesNoVA Disability Rating*Are you the primary caregiver for a service member?*YesNoPlease list other agencies or organizations providing services to the disabled veteran Save and continue later EmploymentAre you currently employed?*YesNoEmployerNameCity, StateStart Date Past EmployersNameCity, StateStart DateEnd DateReason for Leaving Do you have a resume?*YesNoResume Drop files here or Are you currently looking for employment?Career changeEmployed, looking for workUnemployed, looking for workEnhance professional development Save and continue later AccommodationsThe Institute for Advanced Media is an equal opportunity program. Individuals with disabilities may request reasonable accommodations necessary for their participation in the program.Do you require accommodations?*YesNoPlease describe the type of accommodation needed below. Please cite your needs as they apply to employment and learning. Further documentation may be required.* Save and continue later In Your WordsPlease answer the following questions. Answers should be about a paragraph long and should follow a formal writing style that takes into mind grammar and spelling. All answers will be reviewed by the Program Administrator. Please attach your answers as a Word document or PDF.Why have you chosen the Institute for Advanced Media at CPBN?*How will completing course work at the Institute for Advanced Media help or influence your future?*What is one moment in your life that stands out amongst all others? Why did you choose this moment?*How has this moment in time impacted your goals for the future?* Save and continue later Submit ApplicationI certify that the statements I have made on this application are accurate and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatement(s) of fact(s) I will be subject to disqualification or dismissal from the Institute for Advanced Media and to such other penalties as may be prescribed by law or regulations. I understand that this application must be submitted with the required forms and copies of supporting documentation. I understand that space is limited in the Institute for Advanced Media and that submitting an incomplete application will significantly decrease my chance of securing a program slot. I understand that completion of the application does not guarantee admission to the Institute for Advanced Media. I understand that it is my responsibility to make positive contact with the Institute for Advanced Media Program Administrator if there are any changes to this application. I understand that I can update my application by contacting Jennifer Worhle at firstname.lastname@example.org or by calling (860) 278-5310.Student Name* First Last Student Signature*To erase and re-do your signature, click the "reset" icon below the box.Unique IDPhoneThis field is for validation purposes and should be left unchanged. Save and continue later This iframe contains the logic required to handle Ajax powered Gravity Forms.