Student Entry Form – WASHINGTON
2016-17
To be completed by PTA before distribution (ALL FIELDS REQUIRED)
2
Bellevue PTSA REGION__________________
Non-Council … COUNCIL __________________
STATE_________
WA
2.3.75
Sherwood
Forest
PTA
PTA/PTSA: _______________________________ NATIONAL 8-DIGIT ID # __
0 __
0 __
0 __
2 __
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5 __
9 STATE ID # ________________
Jacque
Szymusiak
[email protected]
REFLECTIONS CHAIR NAME: ___________________________________ EMAIL: ________________________________________
425-456-5787
16411 NE 24th St Bellevue WA 98008
PHONE: ________________________________________
PTA ADDRESS: ______________________________________________
Local PTA good standing status:
10/19/16
9/15/16
10/21/16
… Membership dues paid date __________ … Insurance paid date __________ … Standing Rules approval date __________
STUDENT INFORMATION (ALL FIELDS REQUIRED)
11/28/16
Turn-In Deadline:______________________
TEACHER:______________________________
STUDENT NAME: ______________________________________________________ GRADE: _______ AGE:_______ M/F: _______
MAILING ADDRESS: ___________________________________________________________________________________________
CITY: ______________________________________________________________ STATE: _______________ ZIP: _______________
PARENT/GUARDIAN NAME(S): __________________________________________________________________________________
PARENT/GUARDIAN PHONE: _______________________________ PARENT 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. I agree to the above statement and the National PTA Reflections Official Rules.
_________________________________________
Signature of student (REQUIRED)
____________________________________________________________
Signature of parent/legal guardian (REQUIRED if child is under 18 years)
JUDGING INFORMATION (ALL FIELDS REQUIRED)
GRADE DIVISION (Check One)
… PRIMARY (Preschool- Grade 2) … HIGH SCHOOL (Grades 9-12)
… INTERMEDIATE (Grades 3-5)
… SPECIAL ARTIST (All Grades)
… MIDDLE SCHOOL (Grades 6-8)
ARTS CATEGORY (Check One)
… DANCE CHOREOGRAPHY
… FILM PRODUCTION
… LITERATURE
… MUSIC COMPOSITION
… PHOTOGRAPHY
… VISUAL ARTS
TITLE OF ARTWORK: (REQUIRED)________________________________________________________________________________
ARTWORK DETAILS: (Dance/Film: cite background music; Music: musician(s)/instrumentation; Literature: word count; Photo/Visual
Arts: materials & dimensions) ___________________________________________________________________________________
ARTIST STATEMENT: (REQUIRED – 10 words minimum, 100 words maximum describing how your work relates to the theme – use a
separate page if necessary)