Pocoapoco Intake Form

Name

First Name

Last Name

Pronouns

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Instagram handle

A short bio

Please explain the work or research you would like to explore over the course of your stay

How would you describe the personal connection you have with your work or creative practice?

How, if applicable, does your work or practice connect to, impact or communicate with others? With what communities do you work within or alongside?

Allergies and/or Relevant Health Concerns

Pre-existing medical conditions, medications, allergies to foods, or otherwise

Additional dietary restrictions

Accessibility Requests/Accommodations Information

First Emergency Contact Name, Relationship, and Contact Information

Second Emergency Contact Name, Relationship, and Contact Information:

Insurance Information (if applicable)

Insurance Carrier / Primary Holders Name / Policy Number / Group Number / Phone Number

Arrival information

Flight information (flight number, arrival time, and date) + accommodation information and address (if you are not staying at the residency upon arrival)