2021 Next Era TDTD Entry Form

2021 NEXT ERA

TAKE DOWN TOBACCO DAY VIDEO CONTEST

ENTRY FORM

Full Name*

Age*

Grade Level*

Phone*

Email Address*

Name of school enrolled in for the 2020-2021 School Year*

Please list additional student(s) that partnered with you for your video entry.

How did you learn about this contest? Select all the apply.*

Social MediaTeacher/Parent/MentorNewspaperOther

SUBMISSION CHECKLIST

1. Entry Form (this form) 2. Parental Consent/Media Release Waiver/ Release for Participation in Activity document 3. Video Submission(properly labeled)

Please visit www.WeAreNextEra.org/contest for official rules, eligibility, and prizes. Contact NextEra@lphi.org with any questions.