TYPE OR PRINT LEGIBLY IN BLACK INK

STUDENT ENTRY FORM - HISTORY DAY L.A. 2011

Category of Entry: Historical Paper Individual Poster

Individual Exhibit Group Poster

Group Exhibit Individual Documentary

Individual Performance p video p slides p other

Group Performance Group Documentary

p video p slides p other

Individual Website Website Address:

Group Website

Division: Elementary (Grades 4-5) Junior (Grades 6-7-8) Senior (Grades 9-10-11-12)

Phone:

Student's Name: 1. 1. ( )

(If group, list leader first, Last First Area Code

then others in group)

2. 2. ( )

Last First Area Code

3. 3. ( )

Last First Area Code

4. 4. ( )

Last First Area Code

5. 5. ( )

Last First Area Code

Title of Entry:

School Name: District:

Address:

City: Zip:

School Phone: Area Code: Number:

AFFIDAVIT: I have read all the rules of History Day and have prepared my entry accordingly. My entry was completely researched and developed DURING THIS SCHOOL YEAR and is composed of my original work. I have met the guidelines and deadlines of the contest and am aware that the decision of the judges is final.

I understand that neither History Day L.A., Los Angeles County Office of Education, Azusa Pacific University, or its sponsors are liable for any injury, or damage or loss of exhibits or property.

Student's
Signature

Parent's
Signature

Home Address

City Zip

Phone: ( )

I have checked this entry and attest that it conforms to the rules and that this form is legible and completely filled out.

Sponsor Teacher’s Signature

Date

PLEASE PRINT
Name of Teacher:

Home Phone (Required): ( )

School Phone: ( )