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STUDENTNAME_________________________________________GRADE_________AGE________GENDER(optional)_________
PARENT/GUARDIANNAME________________________________EMAIL______________________PHONE___________________
MAILINGADDRESS_______________________________________CITY________________________STATE________ZIP________
Ownershipinanysubmissionshallremainthepropertyoftheentrant,butentryintothisprogramconstitutesentrant’sirrevocablepermissionandconsentthatPTAmaydisplay,copy,reproduce,enhance,print,sublicense,publish,distributeandcreatederivativeworks forPTApurposes.PTA isnot responsible for lostordamagedentries.Submissionofentry into thePTAReflectionsprogramconstitutesacceptanceofallrulesandconditions.IagreetotheabovestatementandtheNationalPTAReflectionsOfficialRules.STUDENTSIGNATURE:____________________________PARENT/LEGALGUARDIANSIGNATURE:___________________________GRADEDIVISION(CheckOne) ARTSCATEGORY(CheckOne) !PRIMARY(Preschool-Grade2) !HIGHSCHOOL(Grades9-12) !DANCECHOREOGRAPHY !MUSICCOMPOSITION!INTERMEDIATE(Grades3-5) !SPECIALARTIST(AllGrades) !FILMPRODUCTION !PHOTOGRAPHY!MIDDLESCHOOL(Grades6-8) !LITERATURE !VISUALARTS TITLEOFARTWORK__________________________________________________________________________________________ARTWORKDETAILS(Dance/Film:citebackgroundmusic;Music:musician(s)/instrumentation;Literature:wordcount;Photo/VisualArts:materials&dimensions)___________________________________________________________________________________ARTISTSTATEMENT(Mustbe10to100wordsdescribingyourworkandhowitrelatestothetheme)
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PTALEADERNAMEJeanCunningham/[email protected]
PTAID00006670PTANAMELaCanadaHighSchoolPTSASTATECA
COUNCILPTALaCanadaDISTRICTPTAFirstREGIONPTA_____________________________
MEMBERDUESPAIDDATE________________INSURANCEPAIDDATE__________________BYLAWSAPPROVALDATE__________________
