MENT - U.S. Fish and Wildlife Service · Contest Ent r y Fo rm ht t p:/ /ww w.fws. go v/ ... o th...
1
Supervising Adult: Fill in the STATE RECEIVING SITE address here (before duplicating) Participants: Mail your art to this address. Junior Duck Stamp Program Conservation and Design Contest Entry Form http://www.fws.gov//birds/education/junior-duck-stamp-conservation-program.php Student Information Please print clearly ___________________________________________________________________________________________________________________ First Name Last Name Age ___________________________________________________________________________________________________________________ Home/Residence Mailing Address (Street or P.O. Box) Email ___________________________________________________________________________________________________________________ City State Zip Code ______________________________________________________ (_______)_________________________ (_______)_________________ Parent Name Parent Daytime Phone and Cell Phone Entry Information _________________________________________________________________________________________________________________ Title Species of bird (from permitted species list) _________________________________________________________________________________________________________________ Medium Used (i.e. acrylic, colored pencil) Conservation Message Write a message explaining what you have learned about wetland conservation and the importance of conserving habitat for wildlife, or why conservation is important to you. Sample messages on website. _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ AUTHENTICITY AND LIABILITY STATEMENT DO NOT COPY THE WORK OF OTHERS. PLAGIARISM IS SERIOUS! STUDENTS, PARENTS, AND TEACHERS, DO NOT SIGN ENTRY FORM WITHOUT READING THE FOLLOWING STATEMENT: I hereby certify that this is my original work and not copied or traced from published photos, magazines, books, illustrations, artists’ published works or other materials protected by copyright laws. I understand that the U.S. Fish and Wildlife Service and other sponsors are not responsible for loss or damage to my artwork. I grant exclusive rights to the U.S. Fish and Wildlife Service and its designees to use, alter, copy, publish, and display my artwork for reproduction and promotional purposes as they see fit without compensation to me, including the use of my photograph if taken at a related Junior Duck Stamp program function or submitted to a state or national coordinator. I further understand that the U.S. Fish and Wildlife Service has the exclusive right to disqualify any entry whose authenticity is questionable. Signature of Student _______________________________________ Date _______________ Signature of Supervising Parent ________________________________________ Date _______________ Signature of Supervising Teacher _______________________________________ Date _______________ Group I Group II Group III Group IV Grades K-3 Grades4-6 Grades 7-9 Grades 10-12 Group (Check One) Supervising Adult / Teacher: Please fill in the following information (Print Clearly) __________________________________________________________________________________________________________ First Name Last Name __________________________________________________________________________________________________________ School / Studio / Organization / Troop Name Daytime Phone __________________________________________________________________________________________________________ Mailing Address City State Zip __________________________________________________________________________________________________________ Email Address Please check one of the following: Parent Teacher Counselor Troop Leader Other For Office Use Only Spanish version of this entry form online at http://www.fws.gov/migratorybirds/pdf/Education/junior-duck-stamp-conservation-program/Spanish%20Forms%20Entry.pdf Para una version espanola de esta forma http://www.fws.gov/migratorybirds/pdf/Education/junior-duck-stamp-conservation-program/Spanish%20Forms%20Entry.pdf Does student have a Social Security or VISA Immigration Number? Yes/No Is student a Foreign Exchange Student? Yes/No Before Mailing Please Remember to: Read the contest brochure. Prepare entry as a horizontal design on 9”x 12” media no more than 1/4" thick. Fill out the Entry Form completely with all required information. Check contact phone numbers for accuracy. Have student, parent, and supervising adult sign the Entry Form. Affix the Entry Form to the back of the entry. Include a completed Reference Form. Confirm the address of your STATE RECEIVING SITE. Postmark Entries by your State Deadline. The following states have special due dates: SC - Jan 10; MD - Feb 1; MA and NJ - Feb 15; MO, OH, and VA - Mar 1. All other states, territories and DC postmark by March 15. If you have questions please contact your state coordinator.
Transcript of MENT - U.S. Fish and Wildlife Service · Contest Ent r y Fo rm ht t p:/ /ww w.fws. go v/ ... o th...
Supe
rvis
ing
Adu
lt: F
ill in
the S
TATE
REC
EIVI
NG S
ITE
addr
ess h
ere (
befor
e dup
licati
ng)
Part
icip
ants
your
art to
this
addr
ess.
Junior
Duck S
tamp P
rogram
Conse
rvation
and D
esign C
ontest
Entry
Form
http
://w
ww
.fws.
gov/
/bird
s/ed
ucat
ion/
juni
or-d
uck-
stam
p-co
nser
vatio
n-pr
ogra
m.p
hp
Stud
ent I
nfor
mat
ion
Plea
se p
rint c
lear
ly__
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rst N
ame
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st N
ame
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Hom
e/R
esid
ence
Mai
ling
Addr
ess
(St
reet
or P
.O. B
ox)
Em
ail
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te
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p C
ode
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Pa
rent
Nam
e
Pa
rent
Day
time
Phon
e
and
C
ell P
hone
Entr
y In
form
atio
n
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_Ti
tle
Sp
ecie
s of
bird
(fro
m p
erm
itted
spe
cies
list
)
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_M
ediu
m U
sed
(i.e.
acr
ylic
, col
ored
pen
cil)
Con
serv
atio
n M
essa
geW
rite
a m
essa
ge e
xpla
inin
g w
hat y
ou h
ave
lear
ned
abou
t wet
land
con
serv
atio
n an
d th
e im
porta
nce
ofco
nser
ving
hab
itat f
or w
ildlif
e, o
r why
con
serv
atio
n is
impo
rtant
to y
ou. S
ampl
e m
essa
ges
on w
ebsi
te.
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AUTH
ENTI
CITY
AND
LIA
BILI
TY S
TATE
MENT
DO N
OT C
OPY
THE
WOR
K OF
OTH
ERS.
PLA
GIAR
ISM
IS S
ERIO
US!
STUD
ENTS
, PAR
ENTS
, AND
TEA
CHER
S, D
O NO
T SI
GN E
NTRY
FOR
M W
ITHO
UT R
EADI
NG T
HE F
OLLO
WIN
G ST
ATEM
ENT:
I h
ereb
y cer
tify th
at thi
s is m
y orig
inal w
ork a
nd no
t cop
ied or
trac
ed fr
om
publi
shed
photo
s, ma
gazin
es, b
ooks
, illus
tratio
ns, a
rtists
’ pub
lishe
d wor
ks
or ot
her m
ateria
ls pr
otecte
d by c
opyri
ght la
ws. I
unde
rstan
d tha
t the U
.S.
Fish a
nd W
ildlife
Ser
vice a
nd ot
her s
pons
ors a
re no
t res
pons
ible f
or lo
ss or
da
mage
to m
y artw
ork.
I gra
nt ex
clusiv
e righ
ts to
the U
.S. F
ish an
d Wild
life
Servi
ce an
d its
desig
nees
to us
e, alt
er, c
opy,
publi
sh, a
nd di
splay
my a
rtwor
k for
repr
oduc
tion a
nd pr
omoti
onal
purp
oses
as th
ey se
e fit w
ithou
t co
mpen
satio
n to m
e, inc
luding
the u
se of
my p
hotog
raph
if tak
en at
a re
lated
Ju
nior D
uck S
tamp p
rogr
am fu
nctio
n or s
ubmi
tted t
o a st
ate or
natio
nal
coor
dinato
r. I fu
rther
unde
rstan
d tha
t the U
.S. F
ish an
d Wild
life S
ervic
e has
the
exclu
sive r
ight to
disq
ualify
any e
ntry w
hose
authe
nticit
y is q
uesti
onab
le.
Sign
ature
of S
tuden
t ___
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Date
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Sign
ature
ofSu
pervi
sing P
aren
t ___
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te __
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_
Sign
ature
ofSu
pervi
sing T
each
er __
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_ Date
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Grou
p I
Gr
oup I
I
Grou
p III
Gr
oup I
V
Gra
des
K-3
Gra
des4
-6
Gra
des
7-9
Gra
des
10-1
2
Gro
up (C
heck
One
)
Supe
rvis
ing
Adu
lt / T
each
er: P
leas
e fill
in th
e fo
llowi
ng in
form
atio
n (P
rint C
lear
ly)
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t Nam
e
Las
t Nam
e
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Scho
ol / S
tudio
/ Or
ganiz
ation
/ Tr
oop
Nam
e
D
aytim
e Ph
one
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__
ing A
ddre
ss
City
Sta
te Z
ip
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Add
ress
Plea
se ch
eck o
ne o
f the
follo
wing
:
Par
ent
Te
ache
r
Cou
nselo
r
Tro
op L
eade
r
Oth
er
For O
ffice
Use
Onl
y
Span
ish ve
rsion
of th
is en
try fo
rm on
line a
t http
://www
.fws.g
ov/m
igrato
rybird
s/pdf/
Educ
ation
/junio
r-duc
k-stam
p-co
nser
vatio
n-pr
ogra
m/Sp
anish
%20
Form
s%20
Entry
Para
una v
ersio
n esp
anola
de es
ta for
ma ht
tp://w
ww.fw
s.gov
/migr
atoryb
irds/p
df/Ed
ucati
on/ju
nior-d
uck-s
tamp-
cons
erva
tion-
prog
ram/
Span
ish%
20Fo
rms%
20En
try.pd
f
Does
stu
dent
hav
e a
Socia
l Sec
urity
or V
ISA
Imm
igra
tion
Num
ber?
Yes
/No
Is
stu
dent
a F
orei
gn E
xcha
nge
Stud
ent?
Yes
/No
Befo
re M
ailin
g Pl
ease
Rem
embe
r to:
Re
ad th
e con
test b
roch
ure.
Pr
epar
e entr
y as a
horiz
ontal
desig
n on 9
”x 12
” med
ia no
mor
e tha
n 1/4"
thick
.
Fill o
ut the
Entr
y For
m complete
ly w
ith all required
inform
ation
.
Chec
k con
tact
pho
ne n
umbe
rs fo
r acc
urac
y.
Have
stud
ent, p
aren
t, and
supe
rvisin
g adu
lt sign
the E
ntry F
orm.
Af
fix th
e Ent
ry F
orm
to th
e bac
k of t
he en
try.
Inc
lude a
comp
leted
Refe
renc
e For
m.
Confi
rm th
e add
ress
of yo
ur S
TATE
REC
EIVI
NG S
ITE.
Po
stma
rk E
ntrie
s by y
our S
tate
Dea
dlin
e. T
he fo
llowi
ng st
ates
hav
e sp
ecial
due
date
s: SC
- Ja
n 10
; MD
- Feb
1; M
A an
d NJ
- Fe
b 15
; MO,
OH,
and
VA
- Mar
1.
All o
ther
stat
es, t
errit
ories
and
DC
postm
ark b
y Mar
ch 1
5.
If yo
u ha
ve q
uest
ions
plea
se co
ntac
t you
r sta
te co
ordi
nato
r.
