YOUTH WRITING AND DESIGN CONTEST ENTRANCE FORM

Full Name ____________________________________ Current Grade _______

Home Mailing Address: (number/street) _______________________________________

(City/town) _______________________________________

(Postal Code) ___________________

Permanent Email Address: _________________ @ ________________ . _______

Home Phone: ________ - ________ - __________

School Name: ____________________________________________

Teacher or Principal’s Name: ____________________________________________

Genre (poem/fiction/essay/art) / Title of Submission(s)

1. _________________ / ______________________________________________________

2. _________________ / ______________________________________________________

3. _________________ / ______________________________________________________

Total Entry Fee Enclosed: $15 for one entry + $10/per additional entry (if any) $________

Please check options:

a. Mail my free one-year subscription to Wordscapes to (check one)

______ my home address. ______ my school.

b. I wish to receive mentorship on the creative work I submitted: Yes ______ No ______

Notes: _________________________________________________________________________

Mail completed entrance form, copies of your creative work, and cheque or money order payable to Ripple Effect Arts and Literature Society to:

Ripple Effect Youth Program P.O. Box 2836 Station Terminal Vancouver, BC V6B 3X2