LJC Youth Essay Contest Registration Form

Student Name*

First NameLast Name

Student Address*

Street Address

Street Address Line 2

CityState

Zip Code

Student Age*

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Address (if different than student)

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

E-mail*

School Name/Location*

School Type*

Student Grade*

How was information about this contest communicated to you? (If other, list place/person)*

Upload Student Logo Photograph *

Upload a File

Upload Student Photograph

Upload a File

Release:

By typing your signature, and selecting the "Submit" button, you are signing this Agreement electronically. You agree that your electronic signature is the equivalent of your manual/handwritten signature on this Agreement.

As a parent/guardian of the above mentioned student, your signature indicates the following: You are aware of your child’s essay submission to the 10th Annual Juneteenth essay contest and give permission for their participation. You and the student have read and understand the contest rules, guidelines and criteria. You understand that they will have their artwork and photograph published electronically and for general public viewing. Submitted artwork/photographs become the property of the Lansing Juneteenth Committee and may not be returned.

Parent/GuardianSignature*

Please type name

Lansing Juneteenth Youth Logo Contest Submission