Gorgas Registration Gorgas Scholarship Competition Step 1 of 6 - Region and Date 0% Date: MM slash DD slash YYYY Presenter Information:Name: First Last Email: Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell Phone:Date of Birth (mm/dd/yy) Paper Information:TitleField of ResearchStudent CertificationI certify that all the information given above is correct to the best of my knowledge and belief; that the research report I am submitting is my own individual work and does not represent the work of a student team. I agree to accept the decision of the judges as final and understand that my complete entry form and research report will not be returned to me but shall become the sole and confidential property of the Gorgas Scholarship Competition. I also agree to permit the Gorgas Scholarship Competition to use all information contained in my entry form in any way for publicity purposes. I certify that I have read and fully understood the information contained in the entry form; that I have complied with all of the rules and meet the eligibility requirements for submitting an entry to the Alabama Science Scholar Search and Gorgas Scholarship Competition. Student electronically sign by typing your full name and date (mm/dd/yy)Do you also plan to participate in AJAS Paper Reading? School Information:School Name:School Website: Principal namePrincipal email Teacher/Sponsor Information:Teacher Name: First Last Teacher Email: Teacher Cell Phone: Local Newspaper Information:Newspaper Name:Newspaper Email:
