Name of Poet: 

Date of Birth: (xx / yy / xx)

Address (street, apt. no.. city, zip)

Phone:

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Indicate your category:  Youth (grades 9-12, up to 18 years) College Students and young adults (up to 25 years) Adults (up to 64 years) Seniors (65 years+)

If you are a student, please name your school or college: 

Title of Poem: 

Copy you poem into the box below.

Please state the specific connection of your poem to Greensboro.  Does your poem focus on specific people, places, or events that are part of Greensboro's history?  How was your poem inspired by Greensboro? Please explain fully and be specific in your responses.

 I verify that I am the author of this unpublished poem.