Creativity Contest Entry.pub

Children’s Mental Health
Awareness Creativity Contest 2015
% Family Connection Gordon County
380 Barrett Road . Calhoun, GA 30701
Email: [email protected]
Phone: 706-602-5139
Contact Information
Student Name (First and
Last)
FIRST NAME
LAST NAME
Address
CITY, STATE
Mailing Address
ZIP
Parent/Guardian Name
(First and Last)
FIRST
NAME
• MR • MS
LAST NAME
Parent/Guardian Address
Address
CITY, STATE
ZIP
Parent/Guardian Email
Parent/Guardian Phone
Student Age
AREA
CODE
PRIMARY NUMBER
AREA
CODE
SECONDARY NUMBER
• Middle School (11—14 years) • High School (15—18 years)
Entry Information
Type of Entry
• Writing
• Poster
Parent or Guardian Release and Signature
Disclaimer: This section must be signed and completed to have your winning work displayed and/or published.
I, _____________________________(print name of parent or legally authorized representative), parent/guardian/legally authorized
representative of ____________________________(print child’s name submitting an entry to the contest), consent to and understand that
entries, once submitted, become the property of Gordon County Suicide Prevention Council and may be used for the purpose of promoting
awareness of children’s mental health issues.
Yo, __________________________ (escriba en letra de molde el nombre del padre, madre o representante autorizado legal), padre/
guardián/representante autorizado legal de ________________________ (escriba en letra del molde el nombre del niño/joven que se
registra en el concurso), doy mi consentimiento y permiso a que el registro y el trabajo creativo, una vez sea sometido, se convierte en
propiedad del Gordon County Suicide Prevention Council y que este puede ser utilizado para el propósito de promover la concientización
sobre los problemas de salud mental en los niños.
SIGNATURE SIGNATURE OF PARENT OR LEGALLY AUTHORIZED
Date Signed/Fecha
Printed Name
REPRESENTATIVE WHOSE NAME IS PRINTED ABOVE ON THIS RELEASE
FIRMA NOMBRE DEL MADRE/PADRE O DEL REPRESENTANTE LEGAL
AUTORIZADO, ESCRITO PORARRIBA
SIGNATURE OF DSHS STAFF RECEIVING THIS FORM
DATE FORM RECEIVED