Reflections Student Entry Form printable pdf download

Student Entry Form

To be completed by PTA before distribution

FULL PTA NAME: COUNCIL __________________ DISTRICT __________________ REGION__________________ STATE_________

PTA/PTSA: _______________________________ NATIONAL 8‐DIGIT ID # __ __ __ __ __ __ __ __ STATE ID # ________________

REFLECTIONS CHAIR NAME: ___________________________________ EMAIL: ________________________________________

PTA ADDRESS: ______________________________________________ PHONE: ________________________________________

Local PTA good standing status:

 Membership dues paid date __________  Insurance paid date __________  Bylaws approval date __________

____________________________________________________________________________________________________________

STUDENT NAME: ______________________________________________________ GRADE: _______ AGE:_______ M/F: _______

MAILING ADDRESS: ___________________________________________________________________________________________

CITY: ______________________________________________________________ STATE: _______________ ZIP: _______________

PARENT/GUARDIAN NAME(S): __________________________________________________________________________________

PARENT/GUARDIAN PHONE: _________________________________________ E‐MAIL: ___________________________________

Ownership in any submission shall remain the property of the entrant, but entry into this program constitutes entrant’s irrevocable

permission and consent that PTA may display, copy, reproduce, enhance, print, sublicense, publish, distribute and create derivative

works for PTA purposes. PTA is not responsible for lost or damaged entries. Submission of entry into the PTA Reflections program

constitutes acceptance of all rules and conditions.

_________________________________________ _______________________________________________________

Signature of student

Signature of parent/legal guardian (required if child is under 18 years)

JUDGING INFORMATION

GRADE DIVISION (Check One)

ARTS CATEGORY (Check One)

 PRIMARY (Preschool‐ Grade 2)  HIGH SCHOOL (Grades 9‐12)

 DANCE CHOREOGRAPHY

 MUSIC COMPOSITION

 INTERMEDIATE (Grades 3‐5)

 SPECIAL ARTIST (All Grades)

 FILM PRODUCTION

 PHOTOGRAPHY

 MIDDLE SCHOOL (Grades 6‐8)

 LITERATURE

 VISUAL ARTS

TITLE OF ARTWORK: __________________________________________________________________________________________

ARTWORK DETAILS: (Dance/Film: cite background music; Music: musician(s)/instrumentation; Literature: word count; Photo/Visual

Arts: materials & dimensions) ___________________________________________________________________________________

ARTIST STATEMENT: (At least 10 words, 100 words max describing how your work relates to the theme)

Reflections Student Entry Form