QUAD CITY COMMUNITY ACTION PROGRAM

LOGO CONTEST PARTICIPANT ENTRY FORM

This application must accompany your unsigned entry.  You can drop off your entry with any QCCAP board member or at the address below.

Name: ___________________________________________

Date of Birth: ____________ 

Street Address: _________________________ City: ________________ State: _____

Zip: _________

Home Phone: ____________________          Phone: ____________________

School Name: ____________________         School Grade: ________

If you are under the age of 18 please have your parent sign this application for you.

___________________________________________                      ____________ 

                        Parent/Participant Signature                                                         Date

Submit entry by November 20, 2003 to:

Quad City Community Action Program

Logo Contest

P.O. Box 67

Mirando City, Texas 78369

Telephone: 361-586-4278

 email:omvarst@granderiver.net