SciComm Video Contest FINAL

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Name of Contestant* This field is required.

First Name

Last Name

Suffix

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Email* This field is required.

example@example.com

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URL of your video posted to TikTok or Instagram* This field is required.You must be the owner of the account/handle and include #chemclash to qualify for this contest

example: https://www.tiktok.com/@chemicalkim/video/7146790515114134827

4

Please review the following video release and sign using this secure portal. Contestants must sign this release to be eligible for prizes and for their submission to be eligible for broadcast during the ChemClash livestream on Oct. 18th, 2022.

5

I {nameOf} hereby grant to the American Chemical Society, its affiliates and licensees (collectively referred to as “the Society”), royalty-free permission, including the exclusive worldwide, to reproduce in all formats, including, but not limited to print, electronic, and/or DVD, the work hosted digitally on the website address {urlOf} (”video”).

6

Signature* This field is required.Use your finger or cursor to sign

Clear

7

List collaborators that you would like to receive credit if your video is shown during the ChemClash

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*Prize winners will be contacted following the live event and must provide valid contact and shipping information to receive their prizes. Failure to do so by the requested date may result in delayed shipment or forfeit of their prize. Individuals residing outside of North America may receive a digital prize in lieu of a physical prize due to international shipping limitations.