We Are Here Video Project Submission Form

We Are Here Video Project Submission Form

1 in 3 Mainers have a disability. Help us remind everyone that disability inclusion matters!
Name*

First NameLast Name
Phone Number
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Video File Upload*

Cancelof
I grant to Disability Rights Maine, the right to use this video footage of me or my child in connection with the above-identified event. I authorize Disability Rights Maine, its assignees and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Disability Rights Maine may use such photographs and/or videos of me/my child with or without my name (indicate below) and for any lawful purpose. I understand that my/my child’s photograph and/or video footage may be used in a wide variety of promotional materials, including newsletters, brochures, annual reports, websites, social networking sites, and other print and digital communications.
Please check the following box:*

I agree
Can we use your name?*

YesNo, initials onlyOther
If other, please describe.
Date *

MonthDayYear
Signature*
Full Name
Parent or Guardian Signature (if applicable)
Should be Empty: