Nebraska Film Competition Consent Form Logo
  • Youth Wellness Initiative: "Disconnected" Idea Competition

    Presented by C Me Grow, Inc. dba Glowmedia in partnership with Clarkson Institute

     

    PARENT/GUARDIAN CONSENT FORM

  • Student Information

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  • Parent/Guardian Information

  • Consent and Acknowledgement

  • I, the undersigned parent or legal guardian of the student named above, hereby give permission for my child to participate in the Youth Wellness Initiative: Disconnected Idea Competition, presented by Glowmedia in partnership with the Clarkson Institute.

    I acknowledge and understand the following:

    • This competition invites Nebraska middle and high school students (ages 13-18) to submit a story idea exploring how social media and phone use impact their lives.
    • Participants must be legal residents of Nebraska and legal citizens of the United States.
    • If selected as a finalist, my child will be paired with a professional screenwriter to develop their idea into a short film script.
    • If chosen as a winner, my child's script will be produced into a short film that supports mental health education as part of this initiative.
    • The winning student and one parent or legal guardian will receive an all-expense-paid trip to Los Angeles (not to exceed $4,999) to participate in the film's production.
    • The value of the trip may be considered taxable income, and a Form 1099 may be issued to the recipient.
    • Glowmedia and Clarkson Institute may use my child's name, age, school, and submitted materials (idea and script) for promotional or educational purposes related to this project.

    I confirm that I have read and understood the program guidelines and consent to my child’s participation. I release Glowmedia, Clarkson Institute, and their affiliates from any liability related to this program.

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  • Media Release

  • I grant permission for Glowmedia and Clarkson Institute to use my child's name, likeness, voice, submitted ideas, and participation materials in promotional and educational media, including online platforms, public screenings, and printed materials.

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  • Please visit glowmedia.org for more information. If you have any questions, please contact Vanessa Reed at vreed@glowmedia.org. 

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