COLORED DOT

REGION #~

"-----

Directions: Please type or print clearly in black or blue ink (do not use pencil). Completely fill 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 Age _ GENDER: o Male o Female _ Grade DMsion (check one) Primary: preschool-Grade 2 D llntermediate: Grades 3-5 D Middle/Junior: Grades 6-8 Senior: Grades 9-12 D D Arts Area (checkone) *UTAH PTA ONLY:

~~

20112012 PTA Reflections Program

I STUDENTENTRYFORM Theme:

''Diversity Means ... "

o Dance Choreography o Film Production

o o o

o 3D ART Music Composition Literature Visual Arts Signed Utah Media Release Inc.:

o THEATRE

Required Artist Statement: Explain how your work relates to the theme (Maximum 250 Words)

I *Must

also use the Attached Artist Statement Form (Print your contact information clearly)

Photography, VISual Ar1s, & 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) ofperson(s) appearing in yourFILM:

w__

(3D) H

_ _ _ _ _ _ _

'---

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: the software, hardware, and file format:
0

Traditional Instrumentation

Synthesizer _

All other Categories using a computer-name

:iIl.l

JIlHi.mjllilml__,cc."C.J

Fold

Herec'WA'iliw

... ,.,(.,

.r,L_#

Wi

Student'sFIf"SI: name Address 1

City

Middle Int. Address2

State:

Last Name:
_

_ _

Phone

(j

Email(j

ZIP:

IgrantoNational anirrevocable, t PTA unlimited todisplay, sell, ublicense, and license copy, s publish, creatend derivative from, ywork a sell works m submitted fortheReflections Program. National isnotresponsible ordamaged Entries notbereturned. PTA forlost works. may Iunderstand thatImust participate intheReflections throughPTA/PTSA standing. Program a ingood Iaffirm thisismyown that original I understand thesubmission work. that ofmyentry intotheReflections constitutes Program acceptance oftheaboveonditions. c Signatureof Student Signatureof ParentILegalGuardian: Reauiredfor studentsunder 18 BYLOCALPTACheckone:b:(PTA
0 PTSA

TO BE COMPLETED Localchairname

Localeight-digitPTAID:.QQO

"2.-2- ~4-~

CrOt;0 'E:\eWlehttlU"Y PIA State IAT ZIP'QqOCOJ E-mail ' (/0 m Phone _( ({10 I) "2.. q2..- 2- \27 ~?; . Local PTAgood standingstatus: Membership Dues PaidDate I fro/Jj BylawsApproval Date ~.!Jl Council ame t:>O\\[ I'?J Govth N
Official PTNPTSAname PTAaddress\2..t.-\-eo City

\0 y- \ Th Oyne./ !;;. \L\-\:7o \1\1. t b '( \ V\ ()nf)e- @ {)mOvt \

'NQods

Woods

c(O~S

*ComDlete Local Box before CODv;na

everychild.onevoice.

2011-2012 Utah PTA Handbook

295