A Science Initiative of Synopsys and Agastya Print the Registration Form, fill it and send it with the required

signatures to the mailing below address. Agastya Center for Science and Engineering, Institution of Engineers Building, Opposite to Indian Express, Ambedkar Veedhi, Bangalore 560001 If you have registered online, then print only Section V in this form, get the form duly signed from the respective people and mail it to us.

APPLICATION / REGISTRATION FORM

SECTION I - Personal Information (Team Leader) Name: Age: Gender: Contact Address:

Phone/Mobile Number: Email Id: Class/Semester: Discipline: College Name: Name of the Lecturer(s) /Advisor(s)

SECTION II Project Partners: (minimum 1, maximum 3) Name: Age: Gender:

Contact Address:

Phone/Mobile Number: Email Id: Class/Semester: Discipline: College Name: Name of the Lecturer(s)/Advisor(s)

Name: Age: Gender: Contact Address:

Phone/Mobile Number: Email Id: Class/Semester: Discipline: College Name: Name of the Lecturer(s)/Advisor(s)

Name: Age: Gender: Contact Address:

Phone/Mobile Number: Email Id: Class/Semester: Discipline: College Name: Name of the Lecturer(s)/Advisor(s)

SECTION III Project Partners: (High school students, maximum 2) Name: Age: Gender: Contact Address:

Phone/Mobile Number: Email Id: Class: School Name:

Name: Age: Gender: Contact Address:

Phone/Mobile Number: Email Id: Class: School Name:

SECTION IV - Project Information Project Title/ question: Category: Abstract: (include objective, methods, hypothesis, research work cited, experiment, data, observations, conclusion, bibliography)

Summary Statement:

Help received in doing the project:

Does your project require AC electrical power? (If Yes, bring your own extension cord) What winning means to the team?

SECTION V - Signatures In consideration of your permitting the undersigned student to take part in the Anveshana 2011-12 Science and Engineering Fair, we waive all claims against Agastya International Foundation and all sponsors for injury to or death of persons or loss or damage of property in any way occurring in connection with Agastya International Foundation and we agree to indemnity and hold them harmless against all such liability. We give permission to Agastya International Foundation to use project descriptions, model, photographs, and other likeness of students for promotional purposes. We understand that only projects entered in competitive categories will be considered for awards and only projects recognized as outstanding by the judges will receive awards, regardless of the category or number of projects in a category. We have Read and Understood the Official Rules and Regulations governing the Anveshana 2011-12 Science and Engineering Fair, mentioned on the website at http://www.anveshana.org/rules.htm and Agree to abide by them.

ENGINEERING STUDENTS: 1 Signature by the Applicant

Seal and Signature by the Head of Institution/college

Signature by the Parent/Guardian

SCHOOL STUDENTS: 1 Signature by the Applicant

Seal and Signature by the Head of

Institution/School

Signature by the Parent/Guardian

Application materials must be mailed/ Registered post to Agastya Center for Science and Engineering Institution of Engineers Building, Opposite to Indian Express, Ambedkar Veedhi, Bangalore - 560001 Note: All applications materials must reach us on or before 30th November, 2011

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