GAE Region Qualifier Form

School System/District*

WINNER – The winner of your system/county/spell-off bee.

RUNNER-UP – Every student that qualifies to attend the Region Bee from your county after the winner. For example, Rome City only has one qualifier, so they have no runner-up. Cherokee has 4 qualifiers so the next 3 after the winner would be runners-up.

ALTERNATE – Using the above examples, for Rome the next student finishing after the winner is the alternate and for Cherokee, it would be student #5.

Region and Finishing Order e.g., Winner, Runner-up or Alternate. (Choose 1)*

Runner-up is any qualifier after the winner, no matter placement.

Speller's Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Gender*

MaleFemalePrefer not to answer

Date of Birth*

Date

Age*

Grade Level*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

#1 Parent/Guardian*

First NameLast Name

Best Contact Number*

Please enter a valid phone number.

Email*

example@example.com

#2 Parent/Guardian

First NameLast Name

Best Contact Number

Please enter a valid phone number.

Email

example@example.com

School Name*

School Phone*

Please enter a valid phone number.

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School County*

Name of Speller's Advocate*

First NameLast Name

Advocate is:*

ParentGuardianSchool Representative

Briefly describe student's school interests, activities, and honors:*

Does the speller have any impediments that could impact the ability to perform in the Bee (e.g., wheelchair, hearing; vision, condition, etc.) If not applicable, enter N/A.

A. Certification

I certify that the information provided on this form is true to the best of my knowledge and that the Qualifier meets all eligibility requirements.

B. Authorization

I hereby authorize the Georgia Association of Educators, hereafter referred to as "GAE," to publish photographs taken of the Qualifier as well as use of Qualifier's Name and likeness, for use in GAE's print, online and video-based marketing tools, and other GAE publications. I hereby release and hold harmless GAE from any reasonable expectation of privacy or confidentiality associated with the images specified above.

C. Further Acknowledgements

I further acknowledge that the Qualifier's participation is voluntary and that Qualifier will not receive financial compensation of any type associated with the taking or publication of photographs or participation in company marketing materials or other company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

D. Release

I hereby release GAE, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with Qualifier's participation.

Certify, Acknowledge and Release: By checking each of these (A,B,C and D) you are agreeing to, acknowledging, and certifying to each of the statements above.*

ABCD

Official Signature of Person Completing and Certifying this form: By entering your NAME here, you are officially "SIGNING" and agreeing to all of the above information.*

PrefixFirst NameLast NameSuffix

Email of Person Completing this form: *

example@example.com

Best Contact Number of Person Completing Form: *

Please enter a valid phone number.

Please attach High Resolution Color PHOTO of Qualifier *

GAE Region Bee Qualifier Form