Healthy Teen Relationships Public Service Announcement Contest

Sponsored by Family Crisis Services- Young Adult Abuse Prevention Program

--------------------------------Submission Form-------------------------------Please submit a separate form for each entry (maximum of two entries). Please fill out this form completely and PRINT CLEARLY. Voting will take place between January 28th, 2013 - February 4th, 2013
Filmmakers Name: ______________________________________________________________ (list all Filmmakers Names) Mailing Address: _____________________________________________________________________________ _____________________________________________________________________________ Phone Number:________________________________________________________________ Email Address: _______________________________________________________________ School Name or Group Name: ____________________________________________________ Name of work submitted: ________________________________________________________ Brief description of work (no more than 50 words; please print legibly in blue or black ink): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Before submitting entry, please check that you have done the following: This entry has been submitted with the knowledge and consent of all participants. All participants have signed release forms which will are attached to this application. The e-mail includes the this form, the release forms, and the link to the video. This entry is the original work of the creators.
By signing below, I grant Family Crisis Services- Young Adult Abuse Prevention Program permission to use my name or photograph and to license, distribute, duplicate, archive, or otherwise promote my work to publicize this awareness campaign and for other educational and/or noncommercial purposes. I understand that Family Crisis Services- Young Adult Abuse Prevention Program reserves the right to make final determinations about all issues related to the PSA Contest.

____________________________________________ _____________ Filmmakers Signature Date _____________________________________________ _____________ Filmmakers Signature Date
Questions or concerns should be directed to: Sarah Gordon at Sarah_g@familycrisis.org or 207-767-4952 X108

Healthy Teen Relationships Public Service Announcement Contest

Sponsored by Family Crisis Services- Young Adult Abuse Prevention Program

PSA Release and Consent Form

PARTICIPANTS NAME: ______________________________________________________ SUBMISSION TITLE: ___________________________________________________________

I agree that for the opportunity to participate in Family Crisis Services- Young Adult Abuse Prevention Programs Healthy Teen Relationship PSA Contest, my PSA submission may be broadcast and distributed without limitation through any means and I shall not receive any compensation for my submission and my participation in the contest. All material submitted to YAAPP become the property of YAAPP and will not be returned. By submitting this PSA, I grant YAAPP an irrevocable, royalty-free right in this PSA submission to use, publish, and otherwise alter in any way YAAPP deems appropriate. I also agree that should it become necessary, I will sign any necessary documentation to effectuate that right and release to YAAPP. I confirm that any and all material furnished by me for this program is either my own or otherwise authorized for such use without obligation to me or any third party. I also agree to the use of my name, likeness, portrait or pictures, voice and biographical material about me for educational, program or series publicity and organizational promotional purposes. I further agree that my participation in the program and my PSA submission confers upon me no rights to use, ownership or copyright. I release YAAPP from all liability which may arise from any and/or all claims by me or any third party in connection with my participation in the program and my PSA submission. It is understood that YAAPP is under no obligation to broadcast the PSA submission. By signing below, I certify that I am at least eighteen years of age and I have read this Release and agree to all of its terms.

___________________________________ Participants Name (please print)

____________ _______________________________ Date Participants Signature

____________________________________________________________________________________ Street Address City State Zip Code If you are under eighteen (18) years of age, your parent or legal guardian must sign below. I, _______________________________________ certify that I am the parent or legal guardian of the above-named minor and on behalf of him/her, as well as myself, I have read this Release and agree to all of its terms. ______________________________________ ____________ _______________________________ Parent/Legal Guardians Name (please print) Date Parent/Legal Guardians Signature

Healthy Teen Relationships Public Service Announcement Contest

Sponsored by Family Crisis Services- Young Adult Abuse Prevention Program

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PSA Requirements:
1. Must be between 30 and 90 seconds in length. 2. All video/audio must be sent as a youtube link to YAAPP@familycrisis.org. 3. All video must be original student work. Students can work individually or submit as a group or class. 4. Each PSA must be submitted with all appropriate application and consent forms. Those can be located on YAAPPs facebook page (http://www.facebook.com/// #!/YAAPP) or by e-mailing Sarah_g@familycrisis.org. 5. With February as Teen Dating Violence Awareness and Prevention month, the video must depict the importance of a healthy relationship. The video must also include the following: A.) 1 in 3 teens experience some form of abuse in their relationship B.) February is Teen Dating Violence Awareness and Prevention Month C.) National Hotline Number: 1-866-834-4356. 6. The video may not depict any trademarks, copyrighted materials, logos, or brand names in the background or on costumes, equipment, and props without written approval. th 7. All entries must be entered by January 28 , 2013 by 4:00pm.

Winning PSA:
1. The winning PSA will be selected by the Young Adult Abuse Prevention Team and will be selected based on organization, clarity, quality, and creativity. 2. The winning PSA will receive $100.00 cash Prize 3. The winning PSA will be posted on YAAPPs Facebook page, youtube channel, and aired at TDVAM events. 4. The winning PSA will be announced by February 4th, 2013.

To Enter:
Submit all entry links to yaapp@familycrisis.org. For any questions or concerns, e-mail Sarah_g@familycrisis.org.