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PTA Reflections

Program

I STUDENT ENTRY FORM

THE: "Diversity Means ... "

Directions: Please type or print clear1yin black or blue ink (do not use pencil). Completelyfillout the form down to and induding the requiredsignatures.Leave the boxed area for local PTA informationblank. 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. Arts Area (d1ed< one) Grade Division (checkone) *UTAH PTAONLY: o Dance Choreography Grade _ o (1:1) Primary: preschool-Grade 2 t#""",,'t-.w. o Film Production o THEATRE o (Yellow) Intermediate: Grades 3-5 Age o Music Composition o 3D ART o Middle/Junior: Grades 6-8 GENDER: o Literature o Male o (~, Senior: Grades 9-12 o Visual Arts o Female o Photography Signed Utah Media ReleaseInc.: . . Teacher _ Track:. _

REQUIRED INFORMATION
Required Artist Statement: Explainhow your work relates to the theme (Maximum 250 Words)
*Must alsousethe Attached

Utah Artist Statement

Form (Print your contact information clearly)

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) of performer(s): Film: Name(s) of person(s) appearing in your FILM: Did you use film-editing software? If so, which software?

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(30)

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_ _ _ _ _

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: 0 TraditionalInstrumentation0 Midi Instrumentation Did you use music composition software? If so, which software? Are lyrics included? If so, how do your lyrics complement your composition? All other Categories using a computer-name the software and file format:. _ _ _

Student'sFirstname Address1 City Phonetiil'

Middle Int. Address2 State: Email~

Last Name: _ ZIP;

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Igrant to National PTAan irrevocable, unlimited license to display, copy, sell, sublicense, publish, and create and sell derivative works from, my work submitted for the Reflections Program. National PTAis not responsible for lost or damaged works. Entries may not be returned. Iunderstand that Imust participate in the Reflections Program through a PTAjPTSAin good standing. Iaffirm that this is my own original work. Iunderstand that the submission of my entry into the Reflections Program constitutes acceptance of the above conditions.
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Signature fStudent o TO BE COMPLETED BY LOCAL PTACheck one: VPTA Localdlair name 0 PTSA

Signature f Parent/Legal o guardian (Required forstudents under18) Local eight-digitPTA

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