Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have any of the practitioners involved identify with any of the following groups? Please select as many as relevant. *

First Nations (Aboriginal or Torres Strait Islander)

Torres Strait Islander only

Culturally and linguistically diverse

Overseas born whose first language is not English

Identify with ancestry

At least one parent born overseas whose first language is not English

LGBTQIA+

People with lived experioence or disability

Female identifying

People living in a regional or remote area

Younger person (under 24 years of age)

Emerging artist in the first 5 years of practice

No specific group

Prefer not to disclose

What medium of work will you be presenting? *

Please note our Minerva Gallery is a small space and limited in exhibition abilities.

Painting

Photography

Sculpture

Jewellery

Digital Art

Other Medium (describe below)

Date

MM

DD

YYYY

Planetary Healing Artists' Association of Australia is on:

Instagram : https://www.instagram.com/healingarts_australia/ Facebook : ttps://www.facebook.com/PlanetaryHealingArtists/ LinkedIn : https://www.linkedin.com/company/planetary-healing-artists-association-of-australia YouTube : https://www.youtube.com/channel/UC43qHegIvYjD-M6z7Rg4gig Twitter : https://twitter.com/healingartsorg/