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Please complete this form in its entirety. One form per STUDENT.  Print and gather all signatures for this document. Attach your check ($10/student payable to Cincinnati Museum Center) and send it to:

 Cincinnati Museum Center

Attn: Chantal Hayes

250 West Court Street

Cincinnati OH 45202


PAYMENT MUST BE RECEIVED BY (February 25th, 2017)

Entry Title:  ________________________________________________________________________________________

Division:         Junior (Grades 6-8)         Senior (Grades 9-12)

Category:  Individual - Documentary         Exhibit                Performance                 Website        Paper

      Group -     Documentary           Exhibit                Performance                  Website      

Student Name:  _____________________________________________________________________________________

Student Email: _____________________________________________________________________________________

(Please supply an address that accepts email from outside addresses so you can be reached if there’s a problem!)

Parent Email:  ______________________________________________________________________________________

School Name:  ______________________________________________________________________________________

School Address:  ____________________________________________________________________________________

Teacher Name:  _____________________________________________________________________________________

Teacher Email:  _____________________________________________________________________________________

As a condition of my participation, I affirm that the entry submitted was researched and developed during this current school year ONLY & that my entry adheres to all general NHD project rules, as well as those applying to my specific category.  I understand that Ohio History Day will not be responsible for loss or damage to exhibits and personal belongings during the day’s activities, and release Ohio History Day from any claims or liabilities of any kind whatsoever, arising from or related to my participation in these activities.  I understand that Ohio History Day may record on photographic film, video, and/or other similar digital media pictures of my participation.

Student Signature:  __________________________________________________      Date:  ________________________

Parent Signature:  ___________________________________________________     Date:  ________________________

Teacher Signature:  __________________________________________________     Date:  ________________________