Instructions: All fields MUST be completed and the agreement statement checked. Please make sure you have read the rules prior to completing this form. If there is more than one student on a project (Elementary, Junior, and Team only), this application must be submitted for each student. Do NOT fill in more than one student's name on a single application.

Reminder: Elementary and Junior division students are still required to complete the one page application or senior division students must complete all applicable ISEF forms (ISEF Rules Wizard) and bring them to the NC Region IV Science Fair on February 20, 2010. Students who do not have the completed forms with them, or have incomplete forms without the required signatures, will not be eligible to participate. Do not forget to send the entry fee form and payment of $4.00 per project by the February 12, 2010 deadline. Failure to submit the fee on time may result in removal from the fair.

The following requested information refers to the APPLICANT

Last Name

First Name

Grade

Age

Gender Female Male

Street Address

City

State

Zip Code

Parent's Name

The following question is being asked only for statistical purposes. The response will have no bearing on the student's participation in or performance at the science fair. The judges will not have access to this information. If you do not wish to answer, there is an "I choose not to respond" selection.

Race I choose not to respond African American American Indian Caucasian Hispanic Native Alaskan Other

The following requested information refers to the applicant's TEACHER

Teacher's Last Name

Teacher's First Name

Teacher's Email Address

The following requested information refers to the applicant's SCHOOL

School Name

School Street Address

School City

School State

School Zip Code

School Phone Number

School County Bladen Columbus Cumberland Harnett Hoke Lee Montgomery Moore Richmond Robeson Scotland

Title of Project

Division Elementary Junior (Grades 6-8) Senior (Grades 9-12) High School Team Project

Category Elementary (No category) Biological Sciences Physical Sciences Earth or Environmental Science Technology/Engineering

I certify that all the information listed above is correct and that I have read and agree to comply with all the rules as set forth by the NC Region IV Science Fair committee. I understand that science fair projects are intended to be a product of student efforts.  Therefore, I certify that I have received help only in terms of direction, suggestions, and/or advice from parents, teachers, or other advisors. I grant permission to the NC Region IV Science Fair to take and use any photos related to the science fair project presented.

Reminder: Do not forget to send the entry fee form and payment of $4.00 per project by the February 12, 2010 deadline. Failure to submit the fee on time may result in removal from the fair.