Federal Reserve Bank of Chicago Video Contest Parent Permission Form

Download and Print All of the fields below must be filled out.
Lead Producer Information
Video Title: _________________________________________________________________________
First name: ______________________________ Last name : _________________________________
Date of birth : ____________________________ Phone number: _____________________________
Address (Street, City, State, Zip code):
___________________________________________________________________________________
Email address: _______________________________________________________________________
Confirm email: _______________________________________________________________________
Parent/Legal Guardian Information
First name: ______________________________ Last name : _________________________________
Phone number: _____________________________
Email address: _______________________________________________________________________
Confirm email: _______________________________________________________________________

Lead Producer

I have read and understand the full Contest Rules and agree to abide by those rules. I have full authority to enter this video into this contest and that the video is original and owned by me. If needed, I have obtained the necessary release and permissions to enter this project. I understand that in the event my submission is selected as a winning entry, and the rights and/or originality of my entry cannot be verified to the satisfaction of the judges, an alternate winner may be selected in my place.

Name: _____________________________________________________ Date: ___________________

Parent/Guardian

I understand my child has submitted an original video to the Federal Reserve Bank of Chicago’s Project Hometown video contest. I grant full permission and authority to the Federal Reserve Bank of Chicago and anyone authorized by the organization, to use, publish, and display my or my child’s image and/or voice as it is contained in the video.

Name: _____________________________________________________ Date: ___________________
If you have any questions, please email Chicago Video Contest.
Finalists must submit a fully completed copy of this document in order for their video entry to be valid.
See checklist for more details.