Student Project Request Form

This form must be submitted 10 working days prior to due date.

Today's Date*

Project Due Date*

Student information*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Yes, I would like to receive e-mail from Arizona Humane Society

School/Institution *

School district (if applicable)

Grade*

College StudentK - 89 - 12Scout

Teacher/Scout Leader Information (name and email or phone number)*

Summarize your project*

Are you a Journalism Student?*

Does this request include required service hours?*

Do you plan to shoot any photography or video as part of your project? If so, what are you interested in shooting and how will it be used?*

(Maximum response 255 chars, approx. 5 rows of text)0/255

Who is your audience? In what format will it be presented? How many people do you estimate will see your presentation?*

(Maximum response 255 chars, approx. 5 rows of text)0/255

By completing this form I understand that I must abide by all rules, regulations, standards, policies and directions provided to me by the AHS. I hold harmless the AHS, its agents/employees/volunteers if I sustain any injury while involved with this project. I will not hold the AHS, its agents/employees/volunteers responsible for any loss of or damage to my personal property. I hereby acknowledge that I will utilize any and all photos/video taken in accordance with this project ONLY for the sole purpose noted above, and I will provide a copy of the completed project sent to AHS within (5) days of the deadline/due date noted above. I will not sell, trade, display, publish, re-produce, copy or distribute these images in any way, shape or form to any other agency, entity or individual for any reason. I understand that should I violate this agreement in any way, I am subjected to legal action including but not limited to, civil action.*