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CREATIVE WRITING ENTRY FORM 2019-2020

POETRY/ SHORT STORY (Circle one)

PLEASE TYPE OR PRINT LEGIBLY IN BLUE OR BLACK INK

Attach one of these forms as the last page of each entry submitted to local and/or state contests

If entering as a co-author please include a page for each author, stapled together.

Story/Poem Title: __________________________________________________________________________

Grade: ______________________ *Word Count (Short Story) ________________

STUDENT: first and last name_____________________________________________________________

Student’s address: ________________________________________________________________________

Street City Zip

PARENT(s): first and last name ____________________________________________________________

Best contact phone number: ______________________________________

Best contact e-mail address: ________________________________________________________________

TEACHER: first and last name: ____________________________________________________________

Teacher’s e-mail address: __________________________________________________________________

Teacher’s best contact phone number: ______________________________

SCHOOL: _________________________________________________________________________

School Address: __________________________________________________________________________

Street City Zip

NEW! LOCAL COUNCIL DEADLINE: Postmarked by_February 1, 2019

*IMPORTANT… The following information MUST be filled out completely on each entry form!

*Local Reading Council: _State Only______________________Region – SO (please circle one)

*Short Story Chair (name): __Barbara Carroll___________________________________________

*E-mail address ___bgcarroll1@_____________Best phone contact__708-805-5550____

*Poetry Chair (name): _____ Barbara Carroll____________________________________________

*E-mail address ___bgcarroll1@_____________Best phone contact__708-805-5550____

Mail entries to: Barbara Carroll

150 Greenwood

Burlington, Iowa 52601

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