Team Captain's Name*

Names of ALL other team members*

Vaccine Category*
TdapHPVMeningococcal ConjugateFlu

Grade*
9101112

School*

Teacher*

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) All submissions MUST be in English only.

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+.

Name*

Vaccine Category*
TdapHPVMeningococcal ConjugateFlu

Grade*
56789101112

School*

Teacher*

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.

Poster Upload*

Accepted file types: jpg, jpeg, png, pdf.
*Only computer-generated posters can be uploaded. Hand-drawn posters must be mailed to: Protect Me With 3+ C/O Springboard 101 Crawfords Corner Road, Suite 4-102R Holmdel, New Jersey 07733 It may take a few minutes to upload. You will receive an email confirmation. Poster files must be submitted with your name and vaccine as the file name. (ex. John-Smith-flu.pdf) All submissions MUST be in English only.

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

Any poster 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+.