about 14 years ago
Required Consent Form for Minor Participants, aged 13 - 17
Surgeon General’s Video Contest: Tobacco- I’m Not Buying It
PARENT/LEGAL GUARDIAN CONSENT FORM
Centers for Disease Control and Prevention
Office on Smoking & Health
Instructions: For participants in the aged 13 – 17 category, your video submission cannot be final until a completed consent form is received by CDC’s Office on Smoking & Health (as defined in the Contest’s Official Rules).
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Minor Contestant’s Information |
Parent/Legal Guardian’s Information |
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Name: |
Name: |
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Address: |
Address: |
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City: |
City: |
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State: |
State: |
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Zip Code: |
Zip Code: |
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E-mail Address or Telephone Number: |
E-mail Address or Telephone Number: |
(Contact information to be used for consent verification purposes only)
Parent/Legal Guardian I represent and warrant that: (A) I have read, understood, and agree to the Surgeon General’s Video Contest’s Official Rules located at http://www.2012sgr.challenge.gov and that minor contestant meets all eligibility requirements listed therein; (B) I understand that minor contestant will be providing certain rights to the Centers for Disease Control and Prevention in connection with submitting an entry in one of the four video contest categories; and (C) I authorize the minor contestant to participate in the Contest by making such Submission and to be bound by the Official Rules.
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Parent/Legal Guardian’s Signature Date
Please return this form by April 22, 2012 or the entry may not be eligible for judging. Scan and email the form to SGReport2012@cdc.gov (subject: SG’s Video Contest) or fax to 770-488-5844 (Attention: Amy Rowland).