OFFICIAL ENTRY FORM

TO ENTER:

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1. An eligible entry consists of: a) Page 1 of this form completed and signed by the student's parent/guardian. b) The artwork submission completed on page 2 of this form. Both pages must be submitted together. 2. For legibility purposes, we encourage you to complete the form on your computer as the elds are editable. 3. Once complete, please print out the form on a light colored 8.5"x11" sheet of paper. Be sure to print on 2 separate pages. 4. Make sure the student's parent or guardian has signed the form on the appropriate line. The entry will not be considered without this signature. 5. Mail your form to the address below. Note all entries must be mailed by March 20, 2012 so please allow enough time.
TO BE COMPLETED BY PARENT/LEGAL GUARDIAN OF STUDENT ENTERING THE CONTEST. All elds are required. STUDENTS NAME

SUPPORTING STATEMENT:
Please tell us briey how your doodle expresses the theme If I could travel in time, Id visit... (max 50 words): FEMALE

Alyssa Michelle Heidorn 14

GENDER: MALE

STUDENTS AGE

It shows the prehistoric times, and that's where I'd visit if I could travel in time.

PARENT/GUARDIANS NAME

John & Irene Heidorn

ADDRESS

4050 Laurel Flat Court

STATE

CITY

Las Vegas

NV

ZIP

89129

PARENT/GUARDIANS PHONE NUMBER PARENT/GUARDIANS EMAIL ADDRESS FULL-TIME SCHOOL NAME

702

496

3639

heidorn@cox.net

West Career and Technical Academy

Entries received without this COMPLETED Entry Form will not be accepted or judged and will be disqualied. Entries must be mailed by March 20, 2012 in order to be considered. Mail entry (packaged carefully so it wont be damaged), with proper postage so that its mailed by March 20, 2012 to:
FOR REGULAR MAIL:

If student is homeschooled, please note this in the school name eld and you will not need to complete the remaining school related elds. SCHOOL ADDRESS
11945 W. Charleston Blvd., Las Vegas, NV 89135

Doodle 4 Google PO Box 9112 Plainview, NY 11803-9112 Doodle 4 Google 35 Pinelawn Road, Suite 207W Melville, NY 11747

FOR OVERNIGHT DELIVERIES:

SCHOOL PHONE NUMBER

702

799

4355

I agree to receive e-mail communications regarding Doodle 4 Google. (not required) By signing below, I acknowledge that I am the parent/legal guardian of the entrant and hereby give my permission for him/her to enter the Doodle 4 Google 2012 Contest. I certify that the entrant is enrolled in a private, public or home school (grades K-12) and is a legal resident of the U.S. I have read the Ocial Doodle 4 Google Contest Rules and acknowledge that this entry is both bound by and adheres to them.

Before mailing, make sure all elds on the form are complete (including supporting statement and parental signature) and artwork is done on the second page of this form. Both pages must be submitted together in order for an entry to be complete. For more details and Ocial Rules, please visit www.google.com/doodle4google

PARENT/LEGAL GUARDIAN SIGNATURE

DATE

OFFICIAL ENTRY FORM

TITLE OF YOUR DOODLE:

CHILDS FULL NAME: STATE:

Alyssa Michelle Heidorn

Grades K-3 Grades 4-5 Grades 6-7 Grades 8-9 Grades 10-12

NV

GRADE GROUP:

USE THIS SPACE TO CREATE YOUR GOOGLE DOODLE:

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