Video Submission Form

Video Submission Form
Producer Information
Please select the option that best describes you from the list
Media Factory service area includes Burlington, Charlotte, Colchester (Rte 15 westbound from Fort Ethan Allen only), Essex Town, Essex Jct., Ferrisburgh, Hinesburg, Shelburne, South Burlington, St. George, Vergennes, Williston, Winooski.
Is this submission being sponsored? Was it produced by someone else?
You need a sponsor.

Strengthening communities through civic engagement and sharing local stories is the core of what we do. That's why we're committed to serving the towns in our service area. A sponsor can be anyone who lives or works in the Media Factory's service area (see above). If you have a sponsor, please have them fill out this form.
Sponsor Info
Sponsor Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Producer Info
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the Producer a minor?
Minor's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Full Name

First NameLast Name

Producer Information