National Pta Reflections Program Student Entry Form printable pdf download

National PTA Reflections® Program

Student Entry Form / Local Entry Only

“The Magic of a Moment”

This informal Student Entry Form is intended for use by students entering the National PTA Reflections®

Program at local levels. Students whose local winning entries are selected to move to the next level of the

competition will complete an official online Student Entry process upon completion of their local level programs.

Grade Level (Check one)

Arts Category (Check one)

Primary (Preschool – Grade 2)

Dance Choreography

Film Production

Intermediate (Grades 3-5)

Literature

Middle School (Grades 4-6

Music Composition

High School (Grades 9-12

Photography

Special Artist (Ungraded)

Visual Arts

What is the Title of your work? _____________________________________________________________

Please provide your Artist Statement here. How does your work relate to the Reflections theme?

Explain your work. (10 word minimum/100 word maximum)

________________________________________________________________________________________

Student First Name: ________________________ Student Last Name: ____________________________

Student Address: __________________________ Student City: __________________________________

Parent Phone Number: _____________________ Parent Email: __________________________________

School Name: _____________________________ Home Room Teacher: ___________________________

(To be completed By Local PTA/PTSA)

Full and Official PTA/PTSA Name: ________________________ Local PTA/PTSA 8-digit ID: ___________

PTA/PTSA Contact Name__________________________________________________________________

PTA Contact Email: ____________________________ PTA Contact Phone: ________________________

National Pta Reflections Program Student Entry Form