SSEF ENTRY Form (Page 1)

Place Participant Label Here
62nd State Science and Engineering Fair of Florida
March 28 – 30, 2017 The Lakeland Center, Lakeland
FFFS Office Use Only
SSEF ENTRY Form (Page 1)
Only original Entry Forms are accepted
Step #1: Choose Section: double check to make sure you select the correct level of competition.
Is this a TEAM PROJECT?
YES
NO
S Senior Section (Grades 9-12)
J Junior Section (Grades 6-8)
Step #2: Project Information: double check to make sure you select the correct category.
Project Category:
ANIM Animal Sciences
ENEV Environmental Engineering
BEHA Behavioral & Social Sciences
IMRS Intelligent Machines, Robotics & Systems Software
BMED Biomedical & Health Sciences
MACO Mathematics & Computational Sciences
CMBI Cellular/Molecular Biology & Biochemistry
MICR Microbiology
CHEM Chemistry
PHYS Physics & Astronomy
EAEV Earth & Environmental Sciences
PLNT Plant Sciences
ENMS Engineering
Project Title: (must match ABSTRACT title): ________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Project Arrangement: COMPLETE ACCURATELY – table configuration CANNOT be changed on site.
TN
Table/No Electricity
TE
Table/Electricity*
FN
Floor/No Electricity
FE
Floor/Electricity*
Please select method of payment for electricity ($70):
Check
Money Order
Purchase Order
• Electricity ($70) payment must accompany this form. Personal checks, school checks, purchase orders,
and money orders must be made payable to the FFFS/SSEF. Electricity for lighting purposes will not
be allowed.
Step #3: Personal Information for Individual Registrant or Team Leader of a Team Project
Note: if this is a TEAM PROJECT, Team Members complete additional pages 3 and 4.
Registrant’s (Team Leader) Name: __________________________________________________________
First Name
Phonetic Spelling:
Middle Initial
Last Name
Sir Title (Jr., II, etc)
__________________________________________ Gender:
First Name
Female
Male
Last Name
*Participant’s OWN Email address (required): ________________________________________________
*It is required that the participant enter his/her OWN EMAIL ADDRESS for ID purposes
Mailing Address:
________________________________________________________, FL______________
Number and Street
Home Phone #:
Ethnicity:
City
_____ - _____ - ________
African American
Caucasian
Date of Birth: ____ /____ /____
American Indian/Alaskan Native
Other
Hispanic
Zip+4
Grade in School: ______
Asian or Pacific Islander
62nd State Science and Engineering Fair of Florida
March 28 – 30, 2017 The Lakeland Center, Lakeland
SSEF ENTRY Form (Page 2)
Step #4: School Information
Regional Science and Engineering Fair:
______________________________________________________________
Full School Name:
________________________________________________________________________________
Mailing Address:
____________________________________________________________, FL ________________
Number and Street
Phone #:
_____ - _____ - ________
City
County: _________________
Zip+4
Public:
Non-Public:
Teacher’s Name REQUIRED: ________________________________________________________________________
Dr., Mr., Mrs., Ms., etc
First Name
Last Name
Teacher’s EMAIL ADDRESS REQUIRED: _____________________________________________________________
Step #5: Signatures (must be originals and use blue ink for signatures)
Certification:
“I hereby state that this exhibit was prepared during the current school year OR is a continuing study and that it is my own
work. I have read and agree to abide by the rules and regulations of the State Science and Engineering Fair of Florida.”
__________________________________________________________________________________________
Student Registrant’s or Team Leader’s Original Signature
Date
“I hereby certify that this exhibit or continuing study was prepared during the current school year and that it has my consent
as an approved Science and Engineering Fair Project. To the best of my knowledge, it is the student’s own work.”
__________________________________________________________________________________________
Teacher’s Original Signature
Date
“I hereby certify that I have reviewed the questions on the RSEF/FFFS Regional Director’s Checklist and have ascertained
that all materials are present as required. I further declare that the Regional Fair’s SRC/IRB has certified that this project
meets all requirements and regulations of the International Science and Engineering Fair (ISEF) and the State Science and
Engineering Fair (SSEF) of Florida.”
__________________________________________________________________________________________
RSEF Director’s Original Signature
Date
Release: The following signatures are required for photographs, videotaping, and media interviews.
“For value received and without further considerations, I hereby consent that all photographs and/or video tape images taken
of me and/or recordings made of my voice and/or written extraction, in whole or in part, of such recordings at the State
Science and Engineering Fair of Florida, by the Florida Foundation for Future Scientists (FFFS) or the University of Central
Florida (UCF), may be used by FFFS and UCF and/or others with the consent of the FFFS and UCF for the purpose of
illustration, advertising, or publication in any manner.”
__________________________________________________________________________________________
Student Registrant’s or Team Leader’s Signature
Date
__________________________________________________________________________________________
Parent’s/Guardian’s Signature
Date
Has your Regional Fair selected you to attend the Intel International Science and Engineering Fair
during May? ____________
62nd State Science and Engineering Fair of Florida
March 28 – 30, 2017 The Lakeland Center, Lakeland
SSEF ENTRY Form (Page 3)
If this is a TEAM PROJECT, additional Team Members complete the following.
Step #6: Signatures (must be originals and use blue ink for signatures)
Member #2 Name:
______________________________________________________________________
First Name
Phonetic Spelling:
Middle Initial
Last Name
Sir Title (Jr., II, etc)
__________________________________________ Gender:
First Name
Female
Male
Last Name
Team Member’s Email address REQUIRED: ____________________________________________________________
*It is required that the Team Member enter his/her OWN EMAIL ADDRESS for ID purposes
Mailing Address:
________________________________________________________, FL______________
Number and Street
Home Phone #:
City
_____ - _____ - ________
Ethnicity:
African American
Caucasian
Hispanic
Date of Birth: ____ /____ /____
American Indian/Alaskan Native
Other
Zip+4
Grade in School: ______
Asian or Pacific Islander
Certification:
“I hereby state that this exhibit was prepared during the current school year OR is a continuing study and that it is my own
work. I have read and agree to abide by the rules and regulations of the State Science and Engineering Fair of Florida.”
Team Member #2 Signature
Date
Release: The following signatures are required for photographs, videotaping, and media interviews.
“For value received and without further considerations, I hereby consent that all photographs and/or video tape images taken
of me and/or recordings made of my voice and/or written extraction, in whole or in part, of such recordings at the State
Science and Engineering Fair of Florida, by the Florida Foundation for Future Scientists (FFFS) or the University of Central
Florida (UCF), may be used by FFFS and UCF and/or others with the consent of the FFFS and UCF for the purpose of
illustration, advertising, or publication in any manner.”
__________________________________________________________________________________________
Team Member #2 Signature
Date
__________________________________________________________________________________________
Parent’s/Guardian’s Signature
Date
62nd State Science and Engineering Fair of Florida
March 28 – 30, 2017 The Lakeland Center, Lakeland
SSEF ENTRY Form (Page 4)
If this is a TEAM PROJECT, additional Team Members complete the following.
Step #6: Signatures (must be originals and use blue ink for signatures)
Member #3 Name:
_________________________________________________________________
First Name
Phonetic Spelling:
Middle Initial
Last Name
Sir Title (Jr., II, etc)
__________________________________________ Gender:
First Name
Female
Male
Last Name
Team Member’s Email address REQUIRED: ____________________________________________________________
*It is required that the Team Member enter his/her OWN EMAIL ADDRESS for ID purposes
Mailing Address:
________________________________________________________, FL______________
Number and Street
Home Phone #:
Ethnicity:
City
_____ - _____ - ________
African American
Caucasian
Hispanic
Date of Birth: ____ /____ /____
American Indian/Alaskan Native
Other
Zip+4
Grade in School: ______
Asian or Pacific Islander
Certification:
“I hereby state that this exhibit was prepared during the current school year OR is a continuing study and that it is my own
work. I have read and agree to abide by the rules and regulations of the State Science and Engineering Fair of Florida.”
Team Member #3 Signature
Date
Release: The following signatures are required for photographs, videotaping, and media interviews.
“For value received and without further considerations, I hereby consent that all photographs and/or video tape images taken
of me and/or recordings made of my voice and/or written extraction, in whole or in part, of such recordings at the State
Science and Engineering Fair of Florida, by the Florida Foundation for Future Scientists (FFFS), may be used by SSEF and
FFFS and/or others with the consent of the FFFS for the purpose of illustration, advertising, or publication in any manner.”
__________________________________________________________________________________________
Team Member #3 Signature
Date
__________________________________________________________________________________________
Parent’s/Guardian’s Signature
Date