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TO ENTER: 1. An eligible entry consists of: a) Page 1 of this form completed and signed by the student's parent/guardian. b) The artwork submission completed on page 2 of this form. Both pages must be submitted together. 2. For legibility purposes, we encourage you to complete the form on your computer as the fields are editable.3. Once complete, please print out the form on a light colored 8.5"x11" sheet of paper. Be sure to print on 2 separate pages.4. Make sure the student's parent or guardian has signed the form on the appropriate line. The entry will not be considered without this signature. 5. Mail your form to the address below. Note all entries must be mailed by March 20, 2012 so please allow enough time.

STUDENT’S NAME

STUDENT’S AGE

PARENT/GUARDIAN’S NAME

ADDRESS

CITY STATE ZIP

PARENT/GUARDIAN’S PHONE NUMBER

EMAIL ADDRESS

SCHOOL NAME

SCHOOL ADDRESS

SCHOOL PHONE NUMBER

By signing below, I acknowledge that I am the parent/legal guardian of the entrant and hereby give my permission for him/her to enter the Doodle 4 Google 2012 Contest. I certify that the entrant is enrolled in a private, public or home school (grades K-12) and is a legal resident of the U.S. I have read the Official Doodle 4 Google Contest Rules and acknowledge that this entry is both bound by and adheres to them.

PARENT/LEGAL GUARDIAN SIGNATURE DATE

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN OF STUDENT ENTERING THE CONTEST.

All fields are required.

If student is homeschooled, please note this in the school name field and you will not need to complete the remaining school related fields.

SUPPORTING STATEMENT:Please tell us briefly how your doodle expresses the theme“If I could travel in time, I’d visit...” (max 50 words): ▼

GENDER: MALE FEMALE

OFFICIAL ENTRY FORM

Entries received without this COMPLETED Entry Form will not be accepted or judged and will be disqualified. Entries must be mailed by March 20, 2012 in order to be considered.

Mail entry (packaged carefully so it won’t be damaged), with proper postage so that it’s mailed by March 20, 2012 to:

Before mailing, make sure all fields on the form are complete (including supporting statement and parental signature) and artwork is done on the second page of this form. Both pages must be submitted together in order for an entry to be complete.

For more details and Official Rules, please visit www.google.com/doodle4google

FOR REGULAR MAIL: Doodle 4 Google PO Box 9112 Plainview, NY 11803-9112

FOR OVERNIGHT DELIVERIES:Doodle 4 Google35 Pinelawn Road, Suite 207WMelville, NY 11747

I agree to receive e-mail communications regarding Doodle 4 Google. (not required)

PARENT/GUARDIAN’S

FULL-TIME

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USE THIS SPACE TO CREATE YOUR GOOGLE DOODLE: ▼

CHILD’S FULL NAME:

STATE: GRADE GROUP: Grades K-3 Grades 6-7 Grades 10-12 Grades 4-5 Grades 8-9

OFFICIAL ENTRY FORM

TITLE OF YOUR DOODLE: