Team Name

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Company / Organization Name:

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Nature of Organization: (select one)

Academic Institution - ( Please note: As an academic team, all prizes shall split equally with the host institution and the team)
Nonprofit
Corporation
LLC
Partnership
Other:

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Team Leader Name:

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Postal Address:

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Title

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Location:

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phone number

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Email

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website

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Team leader Headshot:

Please provide link to headshot or page with headshot

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Link to video:

Please provide link to videos saved online (google drive, dropbox, box, etc)

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Team leader Bio:

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Team Story:

How did your team come together?

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Team Group Picture or science picture:

Please provide link to images saved online (google drive, dropbox, box, etc)

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Other Team member names:

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Institution Affiliation:

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Approach:

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Other:

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How did you hear about the challenge?*

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Are you looking for funding?

YES
NO
IT DEPENDS

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Do you agree to allow The Palo Alto Prize and partner organizations and sponsors, to publish and promote the information shared in this form for marketing/PR opportunities?

YES
YES - but not our scientific approach without our prior approval
NO

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By submitting this Intent to Participate, you hereby agree and understand that you are only expressing an interest to participate in the Palo Alto Prizes and that you are not yet registered in the competition. You acknowledge and agree that submission of an Intent to Participate application or expression of interest in any of the Palo Alto Prizes does not entitle you to any right to or claim on any of the Palo Alto Prizes or the prize organizers and does not create any legally binding obligation on the part of the prize organizers to you. Qualified contestants must first go through a due diligence process before they are accepted into the competition. The terms and conditions with respect to the Palo Alto Prizes will be set forth and agreed to by the parties signatories thereto in a separate written agreement called the Master Team Agreement or a similar written agreement.

I agree to the terms and conditions of this Intent to Participate form.

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Submitted by:

Your full name

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DATE Submitted

INTENT TO PARTICIPATE APPLICATION