ENTRY FORM

Please type. Handwritten forms will not be accepted.

Title of production

Video name: ____________________________________________________ Video length: ___________________

Primary contact (If this was a team effort, list team members in “Video participant” section below.) Student’s name: _______________________________________________________________________________ Age: _______ Grade: ______ Phone/cell number: (_____)____________ Email: ____________________________

Home address: ________________________________________________________________________________

City: ______________________________________________ State: _____________ Zip: ____________________

Video participants (Add additional pages if necessary.)

Name: ___________________________________________________________ Age:_________ Grade:_________

Phone number: (_____)____________ Email: _______________________________________________________

Signature: _________________________________________________________ Date: ____________________

*Parent/guardian signature (if<18): ______________________________________ Date: ____________________

Name: ___________________________________________________________ Age:_________ Grade:_________

Phone number: (_____)____________ Email: _______________________________________________________

Signature: _________________________________________________________ Date: ____________________

*Parent/guardian signature (if<18): ______________________________________ Date: ____________________

Name: ___________________________________________________________ Age:_________ Grade:_________

Phone number: (_____)____________ Email: _______________________________________________________

Signature: _________________________________________________________ Date: ____________________

*Parent/guardian signature (if<18): ______________________________________ Date: ____________________

Name: ___________________________________________________________ Age:_________ Grade:_________

Phone number: (_____)____________ Email: _______________________________________________________

Signature: _________________________________________________________ Date: ____________________

*Parent/guardian signature (if<18): ______________________________________ Date: ____________________

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2018

How did you hear about the contest?

Teacher Friend Facebook Club or organization _________________

O[yes] Website Poster Other ______________________________________________

School/club and teacher/advisor information(For the purpose of awarding matching funds)

Are you submitting on behalf of a high school club or organization? yes no If yes, what is the name of that club or organization? __________________________________________________

Teacher/advisor’s name: _________________________________________________________________________ Phone number: (_____)____________ Email: _______________________________________________________ School name: _________________________________________________________________________________ School address: _______________________________________________________________________________

City: ______________________________________________ State: _____________ Zip: ____________________

Copyright clearances and information - VERY IMPORTANT List all audio and visual sources (music, video footage, etc.) Permission signature or attach documentation

1. ___________________________________________________ 1. ____________________________________

2. ___________________________________________________ 2. ____________________________________

3. ___________________________________________________ 3. ____________________________________

I authorize use of my video for any educational purpose and in any media. I understand that I may be contacted by the media to discuss this contest.

Primary video producer signature: ______________________________________ Date: ___________________

*Parent/guardian signature (if<18): ______________________________________ Date: ___________________

See the website for rules, requirements, and submission information at youngemployeesafety.org/contest. Videos must be postmarked or received no later than 5 p.m., February 1, 2018, to be eligible.

*If participant is under 18 years of age, parent/guardian signature is required.

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