Download SECTION 3: To be completed by all students whose projects involve

NORTHERN CALIFORNIA JUNIOR SCIENCE AND HUMANITIES SYMPOSIUM, 2017
PROJECT PROPOSAL / STUDENT INFORMATION FORM
This document must be completed by ALL students. All fields must be completed
Those students whose project involves (even if only observing) human subjects, invertebrate or nonhuman vertebrate animals, recombinant DNA, tissues, pathogenic agents, or controlled substances will
need to complete additional forms provided later by the program.
This form must be completed and filed no later than February 13th, 2017.
If you have any questions, please contact Ann Miller at [email protected].
When completed, email this form to: Ann Miller [email protected]
Student's Name: ______________________________________________________________________
Name of School: ______________________________________Grade level:
Home/Mobile Phone #: _________________________________________________________________
Email address: _______________________________________________________________________
Where did you conduct your experimentation?
At school: ______
At home: ______
In the field: ______
At a research institution: e.g. university lab, medical center, industrial setting: ________
Name of Research Institution:
Lead Researcher’s signature:
Check here _____ if your project involves humans.
Check here _____ if your project involves non-human vertebrates
Check here _____ if your project involved bacteria or invertebrates
Check here _____ if your project involves recombinant DNA, pathogenic agents, or controlled
Check here _____ if your project involves human or animal
Name of current High School Science Teacher:
Teacher’s email address:
Teacher’s Signature:
Date:
Student's Signature: _________________________________ Date: _____________________________