FRIENDS
OF SOUTHERN HILLS and
SOUTHERN HILLS COUNSELING CENTER
24th ANNUAL WRITING CONTEST
APPLICATION
Student Name (Please Print)
Current Grade Level School Name
Teacher (first and last name)
Short Story Title
Student’s Signature Date
PERMISSION FOR PUBLICATION
Name of Parent(s)/Guardian(s)
Home Address
_____
Home Phone Number
Please check one box:
¨ I grant permission to publish my student’s story using his / her name (circle one).
¨ I grant permission to publish my student’s story anonymously (without publishing his / her name) (circle one).
¨ I do not grant permission to publish my student’s story.
Parent’s Signature Date
Please give your entry, attached to this completed application form, to your teacher or principal or mail it to directly Southern Hills. All entries must be received by Southern Hills on or before December 2, 2011, at the following address:
Marcy Leuck, Executive Assistant
Southern Hills Counseling Center
480 Eversman Drive, P. O. Box 769
Jasper, IN 47547-0769
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