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2011-2012 PTA Reflections

Program

I STUDENT

ENTRY FORM Theme: "Diversity-M-ea-n-s-... "

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Directions: Please type or print clearly in black or blue ink (do not use penCil). Completelyfill out the form down to and induding the required signatures. Leave the boxed area for local PTA information blank. If you need more space, use the back of this form or an extra sheet of paper. Be sure to write your full name on any additional pages. Grade Division (checkone) Grade Age _
GENDER: Male Female Teacher

Ar1sArea (checkone)

UTAH

PTA ONLY:

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Primary: preschool-Grade 2 (Yellow) Intermediate: Grades 3-5 <Meed) Middle/Junior: Grades 6-8 (il~) Senior: Grades 9-12 _ Track: _

o Dance Choreography o Film Production o Music Composition o Literature

D THEATRE D 3D ART

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Visual

Arts

Signed Utah Media

Release

Inc.:

I Title of Art~6'rk:
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Required Artist Statement: Explain how your work (Maximum relates to the theme 250 Words)

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information clearly) Form (Print your contact

REQUIRED

INFORMATION

I *Must

also use the Attached

Artist

Statement

Photography, Visual Arts, & 3D: Give the dimensions of the work in inches, induding mats. L Photography: Location/date of shot: Describe the type of camera and process used in preparing the piece. Visual Arts & 3D: Describe the medium (crayons, oil on canvas, etc.). Dance & Theatre: Name(s) ofperformer(s): Film: Name(s) ofperson(s) appearing in yourFILM:

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(3D) H__ _ _ _ _ _ _

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Was a computer used? If so, name the software and hardware. Dance, Theatre, and Film Production: Credit the background music below (title, composer, and performer). Musical Composition: Name(s) of person(s) who performed your composition: All other categories using a computer-name the software, hardware, and file format:
0 Traditional Instrumentation 0 Synthesizer

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Last Name:

I grantto NationalPTAanirrevocable,unlimited licenseto display,copy,sell,sublicense, ublish,andcreateandsellderivativeworksfrom, mywork submittedfor the ReflectionsProgram. p NationalPTAisnot responsible lostor damagedworks.Entriesmaynot bereturned.I understandthat I mustparticipatein the Reflections for Programthrougha PTA/PTSA goodstanding. in I affirm that this is myown originalwork. I understandthat the submissionof myentry into the ReflectionsProgramconstitutesacceptance the aboveconditions. of

Signatureof Student

Signatureof ParentllegalGuardian:
(Required for students under 18)

TO BE COMPLETED BYLOCALPTACheckone: Localchairname PTAaddress E-mail

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everychild.onevoice.

2011-2012 Utah PTA Handbook

295