Ptareflectionsprogram Studententryform
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1PTA Reflections Program | STUDENT ENTRY FORM
Directions: Completely fill out the form down to and including the required signatures. Leave the boxed area for local PTA information
blank. If you need more space, use an extra sheet of paper. Be sure to label any additional pages.
Grade Division (check one)
Arts Area (check one)
Grade:
Primary: preschool–grade 2
Dance Choreography
Photography
Age:
Intermediate: grades 3–5
Film Production
Visual Arts
Middle: grades 6–8
Literature
Gender M
F
Senior: grades 9–12
Musical Composition
Title of Work (Required
______________________________________________________________________________________
):
Required Artist Statement:
Explain how your work relates to
the theme. (Maximum 250 words)
R E Q U I R E D I N F O R M A T I O N
Dance Choreography: Name(s) of
performer(s):_________________________________________________________________________________________
Film Production: Name(s) of person(s) appearing in your
film:________________________________________________________________________________________________
Did you use film-editing software? If so, which
software?____________________________________________________________________________________________
Dance Choreography and Film Production: Credit the background music below (title, composer, and
performer).___________________________________________________________________________________________
Traditional Instrumentation Midi Instrumentation
Musical Composition:
Check one:
Name(s) of person(s) who performed your
composition:__________________________________________________________________________________________
Did you use music composition software? If so, which
software?____________________________________________________________________________________________
Photography: Location/date of shot:
Describe the type of camera and process used in preparing the
piece._______________________________________________________________________________________________
Visual Arts: Describe the medium (crayons, oil on canvas, etc.).__________________________________________________
Photography and Visual Arts:
Dimensions of the work in inches, including mat.
L
W_____________
Student’s first name
Middle intl.
Last name
Address
Address 2
City
State
ZIP
(
)
Phone
E-mail
I grant to National PTA an irrevocable, unlimited license to display, copy, sell, sublicense, publish, and create and sell derivative works from, my work
submitted for the Reflections Program. National PTA is not responsible for lost or damaged works. Entries may not be returned. I understand that I must
participate in the Reflections Program through a PTA/PTSA in good standing. I affirm that this is my own original work. I understand that the submission
of my entry into the Reflections Program constitutes acceptance of the above condition.
→________________________________________
→
________________________________________________________
Full Signature of student
Signature of parent/legal guardian (necessary if child is under 18 years)
Additional Required State Information:
DISTRICT #12 COUNCIL NAME: Olmsted Falls PTA Council
TO BE COMPLETED BY LOCAL PTA Check one: PTA
PTSA Local eight-digit PTA ID: __ __ __ __ __ __ __ __
TO BE COMPLETED BY LOCAL PTA
00018012
Local chair name _________________________________ Full and Official PTA/PTSA name _________________________________
Olmsted Falls High School PTA
Sandra Graham
44138
Olmsted Falls
OH
PTA address ____________________________________ City _________________________________ State_______ ZIP ________
26939 Bagley Road
slgwhit@cox.net
440
2352588
E-mail ___________________________________________ Phone (_____)_________________________
Local PTA good standing status: Per State By-Laws
Yes No missing requirements___________________________
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