LISTEN/Dear Cancer: 2021 Teen Essay Contest Survey

1.TEEN CONTACT INFORMATION(Required.)

Teen's First Name

Teen's Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

2.SCHOOL INFORMATION(Required.)

Grade

School Name

District

3.ELIGIBILITY - School(Required.)

I am in middle school

I am in high school

I am homeschooled

I am homebound or recieve hospital instruction

Other (please specify)

4.ELIGIBILITY - Residency(Required.)

I live in Minnesota

I do not live in Minnesota

Other (please specify)

7.SELECT AN ENTRY CATEGORY(Required.)

Teen living with cancer or survivor

Teen with friend or family member impacted by cancer

8.If I win, notify me by(Required.)

Email

Phone

9.PARENT CONTACT(Required.)

Parent/Guardian #1 Name

Email

Phone

Parent/Guardian #2 Name (optional)

Email

Phone

10.ESSAY RELEASE for TEENS - Check to agree with the following:(Required.)

·I understand that submitted essays are expected to be original (with the exception of quoted or cited material). I agree that the essay I have submitted is my own original work.

I understand that all essays submitted become the property of Gilda’s Club Twin Cities. I grant Gilda’s Club Twin Cities permission to publish and reproduce my name, age, approved image, and school affiliation.

I also understand that submitted essays may be displayed, in whole or in part, in print and electronic media, including but not limited to brochures, annual reports, presentations, newsletters, direct mail, articles about Gilda’s Club, and other fundraising or marketing materials, including electronically on Gilda’s Club Twin Cities website, Facebook page and other social media: www.Gilda’sClubTwinCities.org

11.Teen Signature & Agreement(Required.)

Teen Electronic Signature

Date

12.ESSAY RELEASE for PARENTS/GUARDIANS (required for all students under the age of 18)- Check to agree with the following:(Required.)

My teen is submitting an entry in a contest hosted and conducted by Gilda’s Club Twin Cities. I have read and reviewed the rules of the contest and I give my permission for my child to enter the contest.

I understand that my teen is going to provide their personal information (including by not limited to: name, address, phone number and email address) to Gilda’s Club Twin Cities. This information will not be shared with any third parties for any reason.

I understand that all essays submitted become the property of Gilda’s Club Twin Cities. I grant Gilda’s Club Twin Cities permission to publish and reproduce my child’s name, age, approved image, and school affiliation.

I also understand that submitted essays may be displayed, in whole or in part, in print and electronic media, including but not limited to brochures, annual reports, presentations, newsletters, direct mail, articles about Gilda’s Club, and other fundraising or marketing materials, including electronically on Gilda’s Club Twin Cities website, Facebook page and other social media: www.Gilda’sClubTwinCities.org

13.PARENT/GUARDIAN AGREEMENT(Required.)

Electronic Parent Signature

Date

14.ESSAY TITLE(Required.)

15.ESSAY UPLOAD

Upload document (.doc or .docx; no PDF’s) Essays must be typed and double-spaced; it is recommended that essays fall between 500 and 2,000 words in length.

No file chosen

If you have issues submitting your essay, please contact Annie.Stone@gildasclubtwincities.org or 952-767-7625.

To learn more about Gilda's Club and our LISTEN/™projects, watch a short EMMY-nominated documentary created by Twin Cities Public Television: LISTEN/Stories of Cancer and Resilience.

LISTEN/Dear Cancer: 2021 Teen Essay Contest

SUBMISSION DEADLINE - midnight January 31, 2020