NAME_______________________________________________

AGE___________ (15 through 19)

STREET ADDRESS_______________________________________________

CITY_______________________________________________

STATE_______________

ZIP_______________

COUNTY_____________________________________________

PHONE_________________________________

EMAIL_______________________________________________

TITLE OF SHORT STORY_______________________________________________

ADULT SIGNATURE___________________________________________________

For ages 15 through 19, ENTRY FORM must be signed by PARENT, GUARDIAN, TEACHER, COUNSELOR, ADULT MENTOR, PROBATION OFFICER, or CLERGYMAN)