Personal Data

First Name*    
Last Name*    
Preferred First Name (Optional)    
If you have a name that is different than your legal first name, what do you prefer to be called?

Email Address*    
Alternate Email (Optional)    
Phone number*    

Date of Birth*         Age*   —Please choose an option—10-1314-1819-21

Address*   
City*      State*  —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY   Zip Code*   

Your School

What is your current school grade*   

Name of your school*   
Address of your school*   
City*     State*   —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY   Zip Code*   

Proposed Submission

The description of the proposed submission consists of:

1. A brief paragraph or two describing your submission (up to 500 words)

2. Submission category (photography, painting, etc)

3. Dimensions of the submissions (for sculpture, painting, and photography submissions)

4. Link to an online portfolio (if available - not required)

NOTE:

• You can type your description of the proposed submission directly into the boxes below; or

• Cut and paste your personal statement from Microsoft Word into the box below.

Please use good grammar and spell-check in the description of your proposed submission!
This is the only method to submit your proposed submission description. We will not accept this via U.S. Mail, fax or email.
Please note that a proposed submission description written by anyone other than the applicant will not be considered. The student (applicant) must write the following proposed submission description in order for the application to be evaluated.

Proposed Submission Description (Limit 350 - 500 words)*
Please address all of the following in your description:

1. The name and a brief description of your submission

2. Medium or techniques used

3. What is the inspiration for your submission

Characters remaining: 3500

Submission Category*
Sculpture and 3-D models - 12in wide 12in depth 24in tall maxPainting/Photography - 8in x 10in min 28in x 40in max (including frame)Performing Arts (dance, music, film, spoken word) - MP4 file 3 minute max

Dimensions of the proposed submission*   

Link to an online portfolio (Optional)   
This can also be links to an Instagram page, TikTok or YouTube videos, etc

Pictures (Optional)
File size limit:2mb. Accepted filetypes: PNG, JPG, & JPEG

Additional Information (Optional)
Please share any other information about yourself that you would like us to know about you. (Limit 250 - 500 words)

Characters remaining: 3500

Demographic Information

What is your Racial/ethnic identity?*   —Please choose an option—Black/African AmericanHispanic/Latino American (non-Caucasian)Native American/Indigenous PeoplesAsian-AmericanPacific Islander

What sex was assigned to you on your original birth certificate?*   —Please choose an option—MaleFemale

How would you describe your gender identity?*   —Please choose an option—FemaleMaleTrans femaleTrans maleNon-binaryGenderqueer/Gender non-conforming

Are you a person with a disability (Optional)   YesNo

Within your family, are you the first generation to pursue any kind of post secondary education?*
Being "first-generation" means that you are the first person in your immediate family to pursue any kind of post secondary education. In other words, neither of your parents has a college degree or completed a professional/vocational certification or apprenticeship. If an older sibling or family member attended college, completed a professional/vocational certification, apprenticeship you are still considered a first-generation student
YesNo

What kind of post secondary education have your parents/guardians pursued (Optional)
If you are in a two parent/guardian home, check off all that apply to both parents/guardians in the home. If you are living in a foster or group home, select "N/A"
College (2 year degree)College (4 year degree)Vocational/Certification ProgramApprenticeship ProgramN/A

How did you hear about this program?*   —Please choose an option—Social MediaWebsiteGoogleOther Search Engine (Yahoo/Bing)Teacher/AdvisorFriendParentAshe Arts & STEM RepPulse Arts RepCreative House RepTeach 1 Reach 1 RepOther

If other, please explain:
Other   

If website please list name of website:
Website   

STATEMENT OF ACCURACY FOR STUDENTS

I affirm that the information presented in this application is true, correct, and complete, to the best of my knowledge. I understand that any false or misleading statements on this application may disqualify me. I understand that this application doesn't guarantee my participation in the competition and that my participation requires approval of my application by the Reflections of Black History Month Children’s Art Competition Committee.

In the event that my submission application is accepted and approved, I authorize the release of my name, likeness, photographs, audio and/or video recordings for publicity purposes. Additionally, as a participant, I understand that I become an alumni of the Reflections of Black History Month Children’s Art Competition and will participate to the best of my ability in appreciation of the generosity of the community.

Incomplete applications or applications that do not meet eligibility criteria will not be considered for this competition.

Do you agree to the above terms and conditions? *
I consent to the conditions.

In order for your application to be eligible for consideration, you must complete the following:

1. Complete all required fields and submit any necessary supplemental materials with your application to the Reflections of Black History Month Children’s Art Competition Committee

2. Click on the "Submit" button below.

Your application will not be considered for the Reflections of Black History Month Children’s Art Competition unless you submit your application before the deadline and comply with Items #1 and #2 stated above. There will be no exceptions!

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