Directions: Complete and submit this form via email with each video

Directions: Complete and submit this form via email with each video entry. Form can be printed, scanned and emailed
or printed, photographed and emailed to [email protected] Please note: A parent or guardian’s signature is
required for any entrant or model under 18.
I grant permission to Maternal and Family Health Services, Inc. (MFHS) to utilize the video submitted to My Way to be Teen Video Challenge,
photographs or videos taken of me (or my minor child) for use in publications such as websites, public relations, and/or brochure development or
otherwise, without notifying me. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be
used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other
compensation arising from or related to the use of the video submission. I hereby agree to release, defend, and hold harmless MFHS and its
programs and its agents or employees, from and against any claims, damages or liability arising from or related to the use of the photographs,
interviews and/or other information used by MFHS and/or the media. I am 18 years of age or older and I am competent to contract in my own name
(or the name of my minor child). I have read this release before signing below, and I fully understand the contents, meaning and impact of this
release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing,
and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
___________________________________
______________________
video title
date
______________________
email used to submit video
____________________________
_____
______________________
______________________
name of entrant
age
signature
parent’s signature (if under 18)
___________________________________
______________________
address (street/city/zip)
phone number
A signature is required for anyone who appears in the video. Please submit a second form if more than four persons
appear in submitted video.
____________________________
_____
______________________
______________________
name of person 1
age
signature
parent’s signature (if under 18)
___________________________________
______________________
address (street/city/zip)
phone number
____________________________
_____
______________________
______________________
name of person 2
age
signature
parent’s signature (if under 18)
___________________________________
______________________
address (street/city/zip)
phone number
____________________________
_____
______________________
______________________
name of person 3
age
signature
parent’s signature (if under 18)
___________________________________
______________________
address (street/city/zip)
phone number
____________________________
_____
______________________
______________________
name of person 4
age
signature
parent’s signature (if under 18)
___________________________________
______________________
address (street/city/zip)
phone number