Street Address__________________________________________________________

City: _________________________________ State: _______ Zip___________Age ___

Social Security #: _____________________ Home Phone #: ______________Sex M F

School: _________________________________E-Mail Address ________________

School Address: _________________________________________________________

Sponsor: __________________________ School Phone #: ______________________

Grade: _______ Division: __________ Category: _____________________________

Project Title: ___________________________________________________________

______________________________________________________________________

Project will sit on:  __ Table  __ Floor   ___ Hang on display board

By signing below I give my permission ______, I do NOT give my permission ______ to use any pictures taken of my/our project and me/us for publicity purposes including posting on the internet.

I certify that the work displayed is totally that of the displaying student(s) that has been done with in the last calendar year.

Student 1 Signature ____________________________________________________

Parent/Gardian 1 Signature ______________________________________________

Sponsor Signature ______________________________________________________
mail to: Calumet Regional Science Fair
              c/o Chemistry Department
              Indiana University Northwest
              3400 Broadway
              Gary, IN 46408

or fax to: (219) 980-6673
or e-mail to lwoz@iun.edu