Duck Stamp Conservation and Design Program and Art Contest

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Junior Duck Stamp Program Conservation and Design Contest Entry Form http://www.fws.gov//birds/education/junior-duck-stamp-conservation-program.php Group (Check One) Grades K-3 Grades4-6 Grades 7-9 Grades 10-12 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 Does student have a Social Security or VISA Immigration Number? Yes/No Is student a Foreign Exchange Student? Yes/No Entry Information Group I Group II Group III Group IV For Office Use Only 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, D.C. and VA - Mar 1. All other states and territories postmark by March 15. _________________________________________________________________________________________________________________ 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. _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ 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 Supervising Adult: Fill in the STATE RECEIVING SITE address here (before duplicating) Participants: Mail your art to this address. If you have questions please contact your state coordinator. 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 _______________ 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
Junior Duck Stamp Conservation and Design Contest Reference Form http://www.fws.gov/birds/education/junior-duck-stamp-conservation-program.php Students in Grade Groups III and IV must submit this reference sheet along with their entry to the Junior Duck Stamp Contest. Remember that visual resources are reference materials and should NOT be copied. Grade Group (check one) Group I □ Group II □ Group III □ Group IV □ Grades K-3 Grades 4-6 Grades 7-9 Grades 10-12 Student Information (Please print clearly) State - First Name, Last Name ___________________________________________________________________________________________________________________ Reference Information While creating your Junior Duck Stamp Contest entry, you likely reviewed many sources. Please include your sources in the space below. 1._________________________________________________________________________________________________________________ 2._________________________________________________________________________________________________________________ 3._________________________________________________________________________________________________________________ 4. ________________________________________________________________________________________________________________ 5._________________________________________________________________________________________________________________ 6._________________________________________________________________________________________________________________ 7._________________________________________________________________________________________________________________ 8._________________________________________________________________________________________________________________ 9._________________________________________________________________________________________________________________ 10.________________________________________________________________________________________________________________ Visit http://www.fws.gov/birds/education/junior-duck-stamp-conservation-program/junior-duck-stamp-contest-information.php for more information about this Reference Form.
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Duck Stamp Conservation and Design Program and Art Contest

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