Name:
______________________________________________(please
print)
Homeroom: _______________
Reading (check one):
Original poem _________
Poem of another _______
Please sign below to indicate your approval of your
child reading a poem at the jam session. Original
poems may also be broadcast at a later date on local
station Guilderland Channel 16 as educational
programming.
Yes, my child has permission to recite poetry at
the Poetry Jam.
Parent signature _____________________________
Address: ___________________________________
City/State/Zip: _______________________________
Telephone: __________________________________
Please attach a copy of your poem/work to this
application and return to your Language Arts teacher
by March 28.
