EarthTeam | MKHC

STUDENT AND ADULT SUPERVISOR SIGNATURES REQUIRED

STUDENT PORTION

Student Name (Print) ________________________________

Class____________________________

Student Address _____________________________________________

City ______________________________ Zip__________________

Student E-mail _______________________________________________________________________

Student Phone_______________________________________________________________________

School Name ________________________________________________________________________

School County ______________________________________________________________________

School Address _______________________________________________________________________

City ___________________________________________________________ Zip__________________

Title of Essay _________________________________________________________________________

I affirm that the referenced essay is entirely my own work. I have submitted both a hard copy and an email copy according to requirements.

Student Signature______________________________________________ Date___________________

TEACHER PORTION

I affirm that the essay titled ________________________________________

is entirely the work of (student name) ________________________________

Teacher/Adult Supervisor Name ____________________________________

Teacher/Adult Supervisor E-mail ___________________________________

Phone_____________________________________

Teacher/Adult Supervisor Signature __________________________________ Date____________________

Return this form along with one (1) hard copy of your essay to:
MKHC Essay Contest
PO Box 4686
Walnut Creek, CA 94956
Fax: (925) 376-1456

AND submit one (1) email copy of your essay to: GeoffC@earthteam.net according to submission requirements.