Hopkinsville-Christian County Public Library



-93345379095 Hopkinsville-Christian County Public Library1101 Bethel Street Hopkinsville, KY 270-887-42632016 Black History Month Elementary Essay Contest Entry FormBrought to you by Hopkinsville- Christian County Public Library and Heritage BankStudent Name:?????Grade:?????????Home Mailing Address:?????Word Count:????????City?????Age:?????????State:?Zip Code:?Phone Number:??????????Parent/Legal Guardian/Teacher:??????????????Parent/Legal Guardian/Teacher Cell Phone Number:?Parent/Legal Guardian/Teacher Email:?????????School Name:???????????????School Mailing Address:???????????????City:?State:?Zip Code:???????????School Phone Number:???????????????Release Statement:As a parent, guardian, or teacher, I acknowledge that my child has written the attached essay. Should he or she win the essay contest, I agree to allow the essay to be distributed publicly. I also understand that if it is discovered my child plagiarized or that the thoughts expressed are not his or her own, the essay will be subject to disqualification. I, ___________________________________________________ (print name of parent/legal guardian/teacher) hereby certify the following:I am the parent/ legal guardian of __________________________________.This student is a resident of Christian County.OrI am the teacher of _______________________________________This student’s parent or legal guardian has signed a release form for public use of the student’s work.This student is a resident of Christian County.The grand prize winner will need a parent or legal guardian to sign a separate release form.______________________________________________________________________Parent/Legal Guardian/Teacher SignatureDate ................
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