VIDEO CONSENT FORM (the “Form”)

MyPlate Fruits and Veggies Video Challenge(the “Challenge”)

Form Instructions

Anyone that appears in the Video must complete and sign this Form. If a minor appears in the Video, the minor’s parent / legal guardian must also sign this Form.

A Submission (as defined in the Competition’s Official Rules) will not be final until a completed Form is received by the USDA Center for Nutrition Policy and Promotion(the “Sponsor”) and ChallengePost, Inc. (the “Administrator”)foreach individual that appears in the Video.The completed Form must be uploaded as part of a Submission via the Consent Upload.

Information of Individual
Appearing in the Video (required): / Parent / Legal Guardian’s Information
(required if the individual is a minor):
Name: / Name:
Address: / Address:
City: / City:
State: Zip Code: / State: Zip Code:
Phone: / Phone:
Email Address: / Email Address:

I represent and warrant that: (A) I have read, understood and agree to the Challenge’sOfficial Rules located at FruitsandVeggies.challenge.gov(the “Rules”); (B) I understand thatI am providing certain rights to the Sponsor and Administrator in connection with the Video, including, but not limited to (i) grantingto the Sponsor and Administrator and others acting on their behalf, an irrevocable, royalty-free non-exclusive worldwide license to use, copy for use, distribute, perform publicly and/or display publicly,create derivative works, and license others to do the same, the Submission, for the purpose of the Challenge, until one year after the announcement of winners, including posting or linking to the Submission on the official Sponsorand Administrator websites and partner websites and making it available for use by the public and (ii) the right and permission to record, copy, reproduce, adapt, edit, summarize, publish, exhibit, distribute, perform and otherwise exploit by any and all uses and media, now known or hereafter devised, throughout the universe until one year after the announcement of winners (collectively, “Use”) my or the minor individual’sappearance, name, likeness, and voice in any manner, format, or context whatsoever (collectively, the “Materials”). Said grant shall include, without limitation, the right for the Sponsor, the Administrator, and those acting on behalf of the Sponsor to use the Materials in and in connection with the Challenge, in any other video, film or television program, in print, electronic and/or photoessay materials and publications, and in all types of advertising and promotion relating to the Challenge; and (C) I hereby waive any right to inspect or approve the Materials or the Use to which such Materials may be applied.

I release, discharge, and hold harmless the Sponsor and the Administrator (collectively the “Releasees”) from and against any and all claims that I (and the minor) may have arising from or in connection with my participation in the Submissionand its related events. I further agree to indemnify, defend, and hold the Releasees harmless against any and all losses, claims, and expenses (including reasonable attorneys’ fees) arising from or relating to being included in the Submission.

Nothing herein will constitute any obligation on the USDA or its affiliates to make any use of any of the rights set forth herein.

______
Individual’s Signature (Must be signed by hand, and not typed, stamped, or computer generated) / ______
Date
______
Parent / Legal Guardian’s Signature
(Required ifindividual is a minor) (Must be signed by hand, and not typed, stamped, or computer generated) / ______
Date

1410416-2

1417437-2