International Call for Writing

ENTRY FORM - Page 1

VSA arts—Writing Project
818 Connecticut Avenue NW, Suite 600
Washington, DC 20006 USA

Please complete a separate form for each submission.

Student’s Name (first name/family name):_______________________

Date of Birth:______________________ Age:_____________________

Parent/Guardian’s Name:______________________________________

Address:____________________________________________________

City:_____________________State/Country:______________________

Zip/Mail code:_____________Telephone: _________________________

E-mail:____________________________________________________

Describe your experience with disability:_________________________

___________________________________________________________

___________________________________________________________

Teacher’s Name (first name/family name):_______________________

School Name:__________________________Department:__________

How did your teacher hear about this call (check all that apply)?
Direct mail E-mail VSA arts Web site Local VSA arts affiliate
Other (please specify) ______________________________________

Title of fiction/nonfiction/poem:_________________________________

___________________________________________________________

Date created (month & year):__________________________________

Language of writing:__________________________________________

Genre of submission (check one): Fiction Nonfiction Poetry

Explain why you selected to write about this particular encounter:
___________________________________________________________

___________________________________________________________

___________________________________________________________

Provide a 2–3 sentence biography: ______________________________

___________________________________________________________

___________________________________________________________

Have you remembered to include the English translation, if applicable?

Have you remembered to write your name and title of the work on all pieces of your entry for
identification purposes?

I hereby declare that I am the creator of the fiction/nonfiction/poem and that the work is original. By signing this agreement, I grant VSA arts the right to use my submission for public relations purposes, including, but not limited to, the VSA arts Web site, newsletter, related media, and exhibition at VSA arts events.

Author’s Signature:____________________________Date:__________

Parent/Guardian’s Signature:___________________________________Date:__________
(For students under 18 years of age)