<p> National PTA Reflections® Program Student Entry Process 2012- 2013 THEME: “THE MAGIC OF A MOMENT”</p><p>This form can be used by students entering a Local PTA Reflections program or for student winners to gather necessary information for completing the official Online Student Entry Process to advance to the next round in the National PTA Reflections Competition. </p><p>Grade Level (Check one): Arts Category (Check one): Male Female  Primary (Preschool – Grade 2)  Dance Choreography Grade:______ Intermediate (Grades 3-5)  Film Production</p><p>Age: ______ Middle School (Grades 6-8)  Literature  High School (Grades 9-12)  Music Composition Date of Birth:  Special Artist (All grades)  Photography _____/____/_____  Visual Arts</p><p>REQUIRED INFORMATION</p><p>Student First Name: ______Student Last Name______</p><p>House ______Advisory Teacher______</p><p>Parent/Guardian Name: ______</p><p>Parent/Guardian Address: ______</p><p>City______State______Zip: ______</p><p>Parent/Guardian Email: ______Parent/Guardian Phone: ( )______</p><p>I grant to 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. 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 conditions. </p><p>→______→______Full signature of student Signature of parent/legal guardian (necessary if child is under 18 years)</p><p>LOCAL PTA INFO Check one: PTA PTSA 8-digit PTA ID: _0 _0 _2 _3 _6 _9 _5 _7 Local chair name: _Elizabeth Daghfal______Official PTA/PTSA name:_Mahone Middle School PTSA______PTA address:_ 6900 - 60 th St______City_Kenosha______State_WI___ZIP_53144_____ E-mail [email protected]______Phone( 262 )_942-6260______Local PTA good standing status: Membership dues paid date __/__/__ Audit Submitted date __/__/__ Bylaws approval date __/__/__ COUNTY__Kenosha______</p><p>(See back for arts category questions) ARTS CATEGORY SPECIFIC QUESTIONS – Answer questions for the arts category relevant to your artwork submission.</p><p>Title of Work ( Required ) ______Required Artist Statement: Explain how your work relates to the theme: (At least 10 words Max 100 words)</p><p>Dance Choreography</p><p>1. What is the title of the dance music? ______</p><p>2. Who is the performing artist or musical group?______</p><p>3. Who is the composer?______Who wrote the lyrics? ______</p><p>Film Production</p><p>1. What is the brand and model of camera that you used? ______</p><p>2. If you used editing software, what kind did you use? ______</p><p>3. If you used background music, what is the title? ______</p><p>4. Who is the performing artist or musical group?______</p><p>5. Who is the composer?______Who wrote the lyrics?______</p><p>6. List the names of the people who appeared in this film. ______</p><p>Music Composition</p><p>1. Are there singers? If so, how many and what are their names? ______</p><p>2. Are there instruments? If so, what instruments? ______</p><p>3. If you used music composition software, what kind did you use? ______</p><p>Photography</p><p>1. What brand and model of camera did you use? ______</p><p>2. What kind of process did you use to prepare your photograph? ______</p><p>3. Location of shot ______Date of shot ______</p><p>4. Dimensions of picture? L______x W______Dimensions with matting (no frames)? L______x W______</p><p>Visual Art</p><p>1. Describe the medium or type of visual art you developed (e.g., crayons, collage, oil on canvas).</p><p>2. Dimensions of picture? L ______x W ______Dimensions with matting (no frames)? L______x W______</p>