Christopher Columbus Awards Printable Entry Form

Title of the Entry:

Please limit title to 45 characters, including spaces and punctuation.

Team Members' Information

Name:

Grade:

Home Address:

City:

State: Zip Code:

Name of School or Organization:

E-mail:


Name:

Grade:

Home Address:

City:

State: Zip Code:

Name of School or Organization:

E-mail:



Name:

Grade:

Home Address:

City:

State: Zip Code:

Name of School or Organization:

E-mail:



Name:

Grade:

Home Address:

City:

State: Zip Code:

Name of School or Organization:

E-mail:

Coach's Information

Name:

School/Organization:

School/Organization Address:

City:

State: Zip Code:

Occupation/Job Title:

Subject(s) Taught:

Grade(s) Taught:

Phone Numbers: (Home) (Business)

Fax Number:

E-mail Address:

Are you a new or returning coach? (Check one) New

How many teams did you form, including those who didn't submit an entry?

How many students participated (not just completed entries)?

How did you find out about the competition? (Check one)
E-mail Website Article (Newspaper/Magazine)
Educator Recommendation Ambassador Recommendation Student
Other:

If someone recommended the competition to you, who recommended it?

OMB, Clearance #: 3145-0023

Federal agencies may not conduct or sponsor a collection of information unless the collection of information displays a currently-valid OMB control number and informs potential persons who are to respond to the collection of information that they are not required to respond to the collection of information unless it displays a currently-valid OMB control number. The OMB control number for this collection is 3145-0023. Public reporting burden for this collection of information is estimated to average 12 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Judi Shellenberger, Executive Director, Christopher Columbus Fellowship Foundation, 110 Genesee Street, Suite 390, Auburn, NY 13021; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

Signatures

We affirm that this entry for the Christopher Columbus Awards is original and has been independently developed by the student members of the team. We verify that all members are currently enrolled in sixth, seventh, or eighth grade and that our coach is 18 years or older. We further affirm that we have read and understand the rules of the competition. We understand that if our team is selected as a finalist, we will attend the Columbus Academy at Walt Disney World® in June 2014. Signatures verify that the information is valid and the lack of signatures by all team members and the coach will disqualify the entry.

Signature of the Team Coach:_________________________________________

Date:_____________________

Signatures of Team Members:

1)_____________________________________________ Date:__________

2)_____________________________________________ Date:__________

3)_____________________________________________ Date:__________

4)_____________________________________________ Date:__________

Optional Team Information

We ask for the cooperation of the team coach in responding to the following questions. This information will be used to determine how and if the competition is meeting its goals, purposes, and audiences. Submission of this information is voluntary. Failure to provide it will not affect your team's chances for an award.

Indicate your community type (check one): Rural Suburban Urban

Indicate the number of student team members who are:

Asian/Pacific Islander Black, not of Hispanic origin Hispanic/Latino

Native American/Alaskan Native White, not of Hispanic origin

Indicate the number of student team members that are: Male Female

Note: Mail one copy of the complete entry. Faxed entry material will not be accepted. Entries must be postmarked by February 3, 2014, or the entry will be ineligible for the competition. Materials that do not meet the rules and regulations will be disqualified. Permission is granted to duplicate this Official Entry Form.

This is a printable form. When you have finished filling in the blanks, press the print key and MAIL COMPLETED ENTRIES TO:

Christopher Columbus Awards
105 Terry Drive, Suite 120
Newtown, PA 18940-3425

Entry Form Instructions on previous page.