Oregon Pta Reflections Program Official Entry Form
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1OREGON PTA REFLECTIONS PROGRAM
OFFICIAL ENTRY FORM
Directions: Please print clearly. This form must be filled out in its entirety, including the required signatures, for all
OREGON PTA Reflections Program entrants. For more writing space, use the back of the form.
Grade _____
___
GRADE DIVISION (check one)
ART AREA (check one)
___ Primary (Preschool - 2)
___ Intermediate (3, 4 & 5)
___ Theater
___ Middle/Junior (6, 7 & 8)
___ Senior (9-12)
___ Three-Dimensional Visual Arts
Title of Work
_____
___
___
___
___
_____
Artist Statement (Required)
_____
___
___
___
_____
_____
___
___
___
___
_____
What inspired you to do this work? ____
___
___
___
_______________
______________________________________
___
___
___
___
___
___
_________
Student’s First Name___________________________ Middle Initial____ Last Name___________________
Address________________________________________________________________________________
City__________________________________________________ Zip plus 4_________________________
Phone_________________________________ Email Address____________________________
Oregon PTA includes Regions, Councils and Local PTA/PTSA Units. I grant Oregon PTA permission to use my works for
commercial or noncommercial use, including but not limited to public presentation of the work and reproduction of the work in
print, electronic and multimedia format to promote the Reflections Program. Oregon PTA may continue to use my work as long
as it has access to an archived copy. Oregon PTA is not responsible for lost or damaged works. Entries may not be returned. I
understand that I must participate in the Reflections Program through a qualifying PTA/PTSA Unit in Good Standing. I affirm that
this is my own original work. I understand that the submission of my entry in the Reflections Program constitutes the above
conditions.
THESE REFLECTIONS CATEGORIES ARE ONLY FOR THE OREGON PTA REFLECTIONS PROGRAM. NO
SUBMISSIONS GO TO NATIONAL PTA.
____________________________________
________________________________________
Signature of Student
Signature of parent/legal guardian (necessary if child is under 18 years)
To be completed by local PTA/PTSA Unit
Circle one:
PTA
PTSA
Region _______
PTA/PTSA Name _______________________________________________________________
Unit Address ___________________________________________________________________
City__________________________________________
Zip Plus 4 ______________________
Local Unit Eight-Digit National PTA ID Number ________________________________________
Local Unit Reflections Chair Name __________________________________________________
Phone (include area code) ________________________________________________________
Email address __________________________________________________________________
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