MLGW ART CONTEST

2023 K-12 STUDENT ART CONTEST ENTRY AND RELEASE FORM
STUDENT INFORMATION
Name

First NameLast Name
GRADE
STUDENT'S EMAIL
example@example.com
STUDENT HOME ADDRESS
CITY/TOWN
STATE
ZIP
PARENT'S CONTACT INFORMATION
NAME OF PARENT OR GUARDIAN

First NameLast Name
PARENTS EMAIL
example@example.com
HOME PHONE NUMBER
WORK PHONE NUMBER
MOBILE PHONE NUMBER
SCHOOL INFORMATION
SCHOOL NAME
SCHOOL ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SCHOOL'S PHONE
SCHOOL'S FAX
TEACHER INFORMATION
TEACHER'S (OR HOMESCHOOL TEACHER'S) NAME

First NameLast Name
TEACHER'S (OR HOMESCHOOL TEACHER'S) E MAIL
example@example.com
TEACHER'S (OR HOMESCHOOL TEACHER'S) PHONE NUMBER(S):
HOME
WORK
CELL
PERMISSIONS & CERTIFICATIONS
Originality Certification I hereby certify that, to the best of my knowledge, the entry described above is an original work by the student named above and contains no copyrighted material.
Teacher's or Home School Teacher's Signature

Clear
Date

MonthDayYear
Date
I hereby certify that by submitting the entry described above into MLGW's "Crisis Crusher" Poster Art Contest, MLGW has permission to use this work in their promotional materials. I grant MLGW, the right to take photographs of me and my child in connection with the Art Contest and use and publish the same in print and/or electronically. I agree that MLGW may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and Web content
Parent's Signature

Clear
Date

MonthDayYear
Date
MLGW ART CONTEST SUBMISSION
TITLE OF ENTRY
ART SUBMISSION UPLOAD

Cancelof
Should be Empty:

2023 K-12 STUDENT ART CONTEST ENTRY AND RELEASE FORM

STUDENT INFORMATION

PARENT'S CONTACT INFORMATION

SCHOOL INFORMATION

TEACHER INFORMATION

TEACHER'S (OR HOMESCHOOL TEACHER'S) PHONE NUMBER(S):

PERMISSIONS & CERTIFICATIONS

MLGW ART CONTEST SUBMISSION