Florida Chemathon 2005

Entry and Registration Form

SCHOOL_______________________________________________________________

PRINCIPAL_____________________________________________________________

ADDRESS______________________________________________________________

PHONE (_______)_____________________

PARTICIPANTS (SCHOOLS MAY SEND UP TO THREE TEAMS)

TEACHERS (UP TO 3, NOT TO EXCEED THE NUMBER OF TEAMS, PLEASE)

______________________; ________________________; _______________________

TEAM I (MAX: 4 STUDENTS) COLOR________________

_________________________________ __________________________________ __________________________________ __________________________________

TEAM II (MAX: 4 STUDENTS) COLOR________________

_________________________________ __________________________________ __________________________________ __________________________________

TEAM III (MAX: 4 STUDENTS) COLOR________________

_________________________________ __________________________________ __________________________________ __________________________________

I certify the eligibility of these students as presently taking or previously having taken high school chemistry as indicated, and as not having enrolled in a college or university chemistry course (AP excepted).

__________________________________ ____________________________________

Signature Title

Registration Fee: Please make checks payable to the Tallahassee Subsection of the American Chemical Society.

Total Number of Participants _______________ x $7.00 = $________________

(Students and Teachers)