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over 7 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).

Minor Contestant’s Information

Parent/Legal Guardian’s Information

Name:

Name:

Address:

Address:

City:

City:

State:

State:

Zip Code:

Zip Code:

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.

 

_________________________________                                        ______________________

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).