PTA Reflections Entry Form
To be completed by PTA before distribution.
LOCAL PTA:  Somers PTA Council           LOCAL PTA ID: 18-018
LOCAL PROGRAM CHAIR: Jannel King   EMAIL:  jannelking@hotmail.com 
PHONE:   (914) 522-4401                          COUNCIL PTA:       Somers
DISTRICT PTA:                                            REGION PTA:  Westchester East Putnam
STATE PTA :  NY                                         MEMBER DUES PAID DATE:   10/1/21
INSURANCE PAID DATE:  5/25/21           BYLAWS APPROVAL DATE:   9/22/2020
Sign in to Google to save your progress. Learn more
Email *
STUDENT NAME *
GRADE *
AGE *
CLASSROOM/TEACHER *
PARENT/GUARDIAN NAME *
PARENT/GUARDIAN EMAIL *
PHONE *
MAILING ADDRESS *
CITY *
STATE *
ZIP *
Ownership in any submission shall remain the property of the entrant, but entry into this program constitutes entrant’s irrevocable permission and consent that PTA may display, copy, reproduce, enhance, print, sublicense, publish, distribute and create derivative works for PTA purposes. PTA is not responsible for lost or damaged entries. Submission of entry into the PTA Reflections program constitutes acceptance of all rules and conditions. I agree to the above statement and the National PTA Reflections Official Rules. *
Required
Student Signature *
Parent Signature *
GRADE DIVISION
Clear selection
ARTS CATEGORY
Clear selection
TITLE OF WORK *
DETAILS - If background music is used in dance/film, citation is required. Include word count for literature. List musician(s) or instrumentation for music. List dimensions for photography/visual arts. *
ARTIST STATEMENT(In 10 to 100 words, describe your work and how it relates to the theme) *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms