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CITRONELLE JUNIOR WOMAN'S CLUB
2004 North Mobile Literary & Arts Contest
ENTRY/CONSENT & RELEASE FORM

 Name: _________________________________________________

 Address: ____________________________________  City: ____________________

 State: _____  Zip Code: ___________ Phone #ís: _____________________________

 Circle Age Division:               elementary               jr. high               high school

 Name of School: _______________________________________________________

 Circle Category:               writing               photography               artwork

 Title of Work: _________________________________________________________

 Caption (description/circumstances for photograph): ________________________

 ______________________________________________________________________

 List speed of film, any special effects, shutter speed, and F/stop: _______________

 ______________________________________________________________________

 I hereby verify that this entry is my original unpublished work and I have read all the qualifications  for my category.  Any reason found otherwise will result in my immediate disqualification and no  refund of entry fee(s) will be given.  I certify that I am enrolled in public or private school, or I am a  home schooled student.  I give permission for my original unpublished work to be published in the  print, T.V. and website medias, along with my picture or likeness for promotional purposes.  I  understand any winning entries will become property of the Citronelle Junior Womanís Club and  non-placing entrants may request the return of their works by writing to CJWC, P.O. Box 172,  Citronelle, AL. 36522.
 
 Entrant Signature: ________________________________________________________

 If under 18, Parent or Guardian Signature: ____________________________________       
 
 *******READ RULES FOR REQUIRED INFO IN YOUR CATEGORY!*******
*******DEADLINE FRIDAY, DECEMBER 31, 2004********

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