Ssef Entry Form (Page 1) - Ssef Florida Page 4
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462nd State Science and Engineering Fair of Florida
SSEF ENTRY Form (Page 4)
March 28 – 30, 2017 The Lakeland Center, Lakeland
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
Middle Initial
Last Name
Sir Title (Jr., II, etc)
__________________________________________
Phonetic Spelling:
Gender:
Male
Female
First Name
Last Name
Team Member’s Email address REQUIRED: ____________________________________________________________
*It is required that the Team Member enter his/her OWN EMAIL ADDRESS for ID purposes
________________________________________________________, FL______________
Mailing Address:
Number and Street
City
Zip+4
_____ - _____ - ________
____ /____ /____
______
Home Phone #:
Date of Birth:
Grade in School:
Ethnicity:
African American
American Indian/Alaskan Native
Asian or Pacific Islander
Caucasian
Hispanic
Other
:
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
: The following signatures are required for photographs, videotaping, and media interviews.
Release
“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
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