I, (Full Name)* , hereby state that all footage, including music and any images, is originally created material, or that I have obtained proper, legal permission to use someone else's copyrighted material. Entries will be void if they are incomplete, late, lost, damaged, or not viewable due to technical error. All entries will become property of North Coastal Prevention Coalition and Vista Community Clinic. I give permission to the North Coastal Prevention Coalition and Vista Community Clinic to use any names, photographs, and digital image or video submissions for advertising, publicity, and promotion purposes. I allow North Coastal Prevention Coalition and Vista Community Clinic the right to reproduce and use my PSA throughout the community. I understand my entry will not be returned. I understand the use of copyrighted materials without permission is a violation of contest rules and will attach copyright permission to my submission if applicable. I am aware that by submitting this PSA, I agree to abide by all contest rules and regulations.

I, (Full Name)* , authorize North Coastal Prevention Coalition, Vista Community Clinic and its affiliates, subsidiaries, divisions, members, directors, officers, agents, employees and independent contractors (referred to collectively herein as ‘VCC’), to use and disclose my image in photographs and/or video footage taken of me and to disclose protected health information about me, including my name, age, program participation and events in promotional marketing, instructional, or educational projects (“projects”) that show how the programs of the VCC and the North Coastal Prevention Coalition help people throughout its service area.

The Projects may be disclosed to governmental agencies, corporate or individual donors, foundations and to the public in general, and may include, but are not limited to: videos, newsletters, websites, reports, brochures, press releases, presentations, exhibits, displays, PowerPoint presentations, social media activity, annual reports, applications, fund-raising activities, and appeal letters. I waive any rights of compensation or ownership of such photographs (images) and/or video footage taken of me. 

This authorization may be revoked at any time if notification of such revocations is submitted in writing to Vista Community Clinic. Such revocation may either be hand-delivered or mailed to Vista Community Clinic at 1000 Vale Terrace Vista, CA 92084. I understand that I will not be able to revoke my authorization if the VCC has removed my image or my protected health information from Projects already disclosed.

I understand that photographs (images) and/or video footage of me and other protected health information about me may be used on social media sites and that, once posted on the internet, such images and information are almost impossible to recall.