The Friends of Southern Hills
and
Southern Hills Counseling Center
22nd Annual Writing Contest
APPLICATION
Student Name
Current Grade Level School Name
Teacher (first and last name)
Short Story Title
Student’s Signature Date
PERMISSION FOR PUBLICATION
Name of Parent/Guardian
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 11, 2009, at the following address:
Judy Hunsicker, Executive Assistant
Southern Hills Counseling Center
P. O. Box 769
Jasper, IN 47547-0769
|
|
|
|