This Form Must Be Included As Part of Every Submission to the Climate Champion Competition

This form must be included as part of every submission to the California Climate Championscompetition. All fields on this form must be fully completed in legible hand-writing or typed using acomputer. Entries accompanied by incomplete entry forms cannot be considered by the judges.

Full Name:

Home mailing address:

Age as of Feb. 11, 2008:

Date of Birth:

Primary telephone number:

Email address:

Name of parent or guardian:

Relationship to entrant:

Daytime contacttelephone number:

Cell phone number (if applicable):

Email address:

School name and full address (if applicable):

Name of teacher and phone number (if applicable):

My news report is:

Web page(max 500 words) Video clip(max 3 mins) Radio report(max 3 mins) Newspaper article(max 500 words)

Filename:

Please note that not all file types will be accepted. Refer to the technical requirements for details(see:

Please supply any additional information about your entry (e.g., web address if you have created a website).

Region (please check one)

Northern California Central California Southern California

I agree to the terms & conditions of the competition (see:

Using no more than 200 words, please tell us a little bit about yourself and why you think you should be chosen to be a Climate Champion.

How did you hear about this program?

School announcement/publicity Teacher or Guidance Counselor

Youth organization/youth leader Print Media Online advertising

Website (please specify site):

Other (please specify):

Submission Instructions

Completed entry materials, including this form and your news report, should be emailed to: . If your file is larger than 5MB,please review the File Submission Information page for FTP uploading instructions. Although electronicapplications are strongly preferred, entries may be mailed to: Climate Champions, Air Resources Board, Research Division, P.O. Box 2815, Sacramento, CA95812. News reports submitted by mail should be on a CD and of a file type as listed in the Technical Requirements.

APPLICATION CHECKLIST

Have you:

Completed all your details on this entry form?

Made sure you have provided all requested contact information?

Told us what kind of news report you are sending and the filename?

Completed your 200-word personal profile?

Submitted your news report?

Made a copy of all of your submission materials to keep for yourself?

ALL ENTRIES MUST BE RECEIVED BY FEB. 11, 2008, Midnight 12AM PST