Kentucky Heritage Land Conservation Fund PSA Video Contest Entry Form
Name: Date of Birth:
Street:
County: City: State: Zip Code:
Email Address:
Phone: Cell:
City, State:
Grade level and major, if currently enrolled in college or university:
Group Name: # of members in Group:
Group Information:
Faculty Advisor Name and Department:
School or University:
Faculty Advisor Contact Information:
Name:
Street:
County: City: State: Zip Code:
Email Address:
Phone: Cell:
Additional Information:

I understand that this PSA submission is to be treated as free of restrictions and limitations regarding its use, reproduction, and publication, and I acknowledge that it will become the sole property of the Commonwealth of Kentucky, Kentucky Heritage Land Conservation Fund.

I state that this is an original submission and was created legally, nor dies it created infringe on the intellectual property, privacy or publicity rights or any other legal rights of any third party. I have obtained permission from each person whose name; image, likeness or voice ("likeness") is included in the submission. All involved parties have granted me the rights to use their likeness as described in these rules. This includes written permission from the parent(s) or legal guardian(s) of any minors involved.

The PSA Video submitted herewith is my own work and complies with conditions of this contest.

Applicant Date

Parent or Legal Guardian Date

Faculty Statement of Endorsement

I, ______certify that the submitted entry to the Kentucky Heritage Land Conservation Fund PSA Video Contest has been completed by the following students and I have written consent of every involved minor’s parent (s) or Legal Guardian. All complies with conditions of entry into this contest.

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Faculty Member Date

An Artist’s Statement of Originality – Individual Submission

Please explain in 200 words or less how you (or the group) came up with the concept and message featured

in the submission.

*Team Name______Number of Members______

*The same statement can be submitted as one “over all statement” for a team submission.

Applicant Date

Parent or Legal Guardian Date

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