Team Captain's Name*

Names of ALL other team members*

Vaccine Category*
TdapHPVMeningococcal ConjugateFlu

Grade*
56789101112

School*

Teacher (if applicable)

Nurse (if applicable)

Student Best Contact Phone Number*

Student Email*

Parent/Guardian Cell Phone Number*

Parent Email*

How did you hear about Protect Me With 3+?*
A teacherAnother studentYour parent/guardianA doctor or nurseEmailTwitterFacebookThis is a class project
Please select all that apply.

Video File*

Accepted file types: avi, mov, mp4, mpegps, wmv, wmv2.
It may take a few minutes to upload. You will receive an email confirmation. Video files must be submitted with the name of the Team Captain and vaccine as the file name (ex. John-Smith-flu.mov). Files must be 6MB or less.

Agreement*
I, student, have read and agree to all rules of the Protect Me With 3+ Contest and certify that this video is my original work.

I, parent/guardian, have read and agree to all rules of the Protect Me With 3+ Contest and witness that this video is the original work of the student above.

I, parent/guardian, have read and agree to the COPPA Disclosure.

View COPPA Disclosure here.

I have received permission to include all students who appear in my video.

Any video entry submitted into the Protect Me With 3+ Contest becomes the property of Protect Me With 3+ and its sponsors and may be displayed, published, donated or used in any way deemed appropriate to meet the goals of Protect Me With 3+.

Team Captain's Name*

Names of ALL other team members*

Vaccine Category*
TdapHPVMeningococcal ConjugateFlu

Grade*
56789101112

School*

Teacher (if applicable)

Nurse (if applicable)

Student Best Contact Phone Number*

Student Email*

Parent/Guardian Cell Phone Number*

Parent Email*

How did you hear about Protect Me With 3+?*
A teacherAnother studentYour parent/guardianA doctor or nurseEmailTwitterFacebookThis is a class project
Please select all that apply.

Upload Videos *

Accepted file types: avi, mov, mp4, mpegps, wmv, wmv2.
It may take a few minutes to upload. You will receive an email confirmation. Video files must be submitted with the name of the Team Captain and vaccine as the file name (ex. John-Smith-flu.mov). Files must be 23MB or less.

Agreement*
I, student, have read and agree to all rules of the Protect Me With 3+ Contest and certify that this video is my original work.

I, parent/guardian, have read and agree to all rules of the Protect Me With 3+ Contest and witness that this video is the original work of the student above.

I have received permission to include all students who appear in my video.

Any video entry submitted into the Protect Me With 3+ Contest becomes the property of Protect Me With 3+ and its sponsors and may be displayed, published, donated or used in any way deemed appropriate to meet the goals of Protect Me With 3+.