KIS Video Contest - Release Form 2023-2024

Keeping it Safe -KIS-

Under 21 Alcohol Prevention Coalition

Student Video Contest Consent and Release Form

Montgomery County, Maryland

Full Name*

Email Address*

Phone Number*

Name of Video*

School or Youth Group*

Teacher/Adult Advisor*

I hereby consent to the use of my likeness and/or voice by the Keeping it Safe Coalition and its assigns, for all purposes of education, instruction, or public information, on the Montgomery County’s Keeping it Safe website, social media platforms and YouTube Channel and the Montgomery County Public School’s (MCPS) web site, and the MCPS YouTube site. The use of this content is for educational purposes only.

I am of legal age* and competent to execute this consent and release, which I have read and fully understand.

Print Name*

Date*

Date of Birth*

Signature *

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Use your mouse or finger to draw your signature above

* If you are under age 18:

Parent/Guardian Name*

Parent/Guardian phone or email address*

Parent/Guardian Signature*

[clear]

Use your mouse or finger to draw your signature above