.

Creator/Contributor’s Name: ___________________________________________________________

Role(s): (Please check all that apply) Creator (Prize recipient) Co-Creator (Prize recipient)

Actor/Actress Voiceover Other:______________________________________

High School:_________________________________________________________________________

High School Street Address: ____________________________________________________________

City:_______________________________________________ State:______ Zip:________________

Email (optional): _____________________________________________________________________

Video Title : _________________________________________________________________________

Brief summary of video: _______________________________________________________________

___________________________________________________________________________________

Source of music: _____________________________________________________________________

Source of royalty-free images: __________________________________________________________

By signing this form, the contributor assigns to the public agencies who are members of the Russian River Watershed Association, nonexclusive permission to use, copy, and distribute the submitted video for public information or educational purposes. The permission granted includes permission to alter or edit the video. The contributor acknowledges that receipt of prize money constitutes payment in full for this permission, without further consent or compensation. The contributor acknowledges that no copyrighted material has been used and that the video was student-created.

Russian River Watershed Association’s High School Video Contest Entry, Use, and Release FormEach person involved in the production of the video must fill out this form. You may sumbit this form online at: www.sonomawater.org/video-contests or mail to: Kory Hebner, Sonoma Water, 404 Aviation Boulevard, Santa Rosa, CA 95403.

______________________________ ________________________________ __________________Name (print) Signature Date

______________________________ ________________________________ __________________ Parent / Guardian Name (print) Parent / Guardian (signature) Date

______________________________ ________________________________ __________________ Teacher or Principal (print) Teacher or Principal (signature) Date

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