Video Contest Submission Form – ADHD Awareness Month

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Approved

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No

Comment?

submitter notified? (kerch only)

Yes
No

Final URL

https://www.adhdawarenessmonth.org/?p=

Your Name*

Videographer if different from above

Your email address*

Enter Email Confirm Email

Phone

Entry Category*

Family: You are part of a family with a child under the age of 18 with ADHD
Child: You are a child under the age of 18 who has ADHD
Adult: You are 18 or older living with ADHD
Professional: You provide support to individuals living with ADHD or are a board member or employee of an ADHD organization *no prizes awarded*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Actors in this video are*

Only me
My family and/or me
Other people, too

Please list other actors from your family who appear in this video*

You must have a signed copy of the Actor release form
for each actor who is not in your family. (or actor's guardian if the actor is younger than 18)
Download the Actor/Model Release form here
Also please supply the information in the following form.

Model Permissions Granted

The Model(s) granted the Photographer permission to photograph and/or film and sound record the Model and furthermore grant permission to use the resulting work ("the Work") according to the terms stated hereunder:
1. Any permission granted to the Photographer shall extend to his/her successors, legal representatives, licensees and assigns and shall be irrevocable and perpetual without any further or additional claim for compensation by the Model.
2. Use of the Work shall be unrestricted as to location, quantity or frequency, may be for any purpose and in any medium whatsoever, whether foreseen or unforeseen at this time, except where such use is in contravention of the law.
3. Permission is specifically granted for the Work to be edited, altered, distorted, used in whole or in part, in conjunction with other images, graphics, text and sound in any way whatsoever and without restrictions.

Full legal name of additional actors*

List additional actors separated by comas

Telephone numbers of actors*

List additional actors separated by comas

Email addresses of actors

List additional actors separated by comas

Full address of actors*

Each of the following will require a check box in order to submit the form.*

I certify that I have not used copyrighted, trademarked or branded material, including music or images in my video. I have not included photos, music or images that I stole or downloaded that belong to someone else.

*

All of the people appearing in the video know they are in the video and have read this video release agreement. If they are not included on the submission form as members of my family, I have included a separate signed release from them or their parents/guardians if they are under 18 years of age.

*

I acknowledge that ADHDAwarenessMonth.org and the coalition member organizations of ADHD Coaches Organization (ACO), Attention Deficit Disorder Association (ADDA) and Children and Adults with ADHD (CHADD) (“the coalition”) have my permission to use the video and my image and statements (or those of my minor child/children) during the contest period and for any organizational purpose after the contest, without notification, consent or compensation. Organizational purpose includes, but is not limited to, displaying the video on the internet, at conferences, or at other venues, regardless of whether fees are charged.

*

I understand that I will not be paid for the use of the video and my image and statements should the video be used for organizational purposes after the contest.

I have read and understood this Agreement*

and I am fully familiar with all the terms therein.

Video Title*

Video description*

Please give us about 20 words about your video (125 characters including spaces)

How long is your video?*

Videos should not be longer than about 2 minutes

Video submission logistics*

I have already added my video to YouTube
I want to attach it to this form
I can't make this work

URL of YouTube Video

Please do not use short codes. We need the actual YouTube URL

Upload your video here

Be sure to wait til it's fully uploaded before closing this window

If you can't get your video to upload and you can't put it on YouTube yourself,
then you must contact webmaster@adhdawareness.org for additional help.
That will require you to be able to store your video
somewhere where we can get to it.
For example a DropBox account or some other storage facility.

Email

This field is for validation purposes and should be left unchanged.