Contact Us Search: All EPA This Area

EPA, CDC and HUD Lead Poisoning Prevention Video Contest Entry Form
(One entry form per video)

Full Name:

E-mail:

Phone:

Street Address:

Street Address 2:

City:

State:

ZIP Code:

Video Title (unique name):

YouTube User Name:

YouTube URL:

Has the video been uploaded to the contest group page?

Date video was uploaded:

How did you hear about the contest?

Are you, or a member of your immediate family, an EPA, CDC or HUD employee, contractor or grantee?

Do you agree to the Rules?

Age:

Parent/Guardian Full Name (if under 18):

Parent/Guardian E-mail:

Parent/Guardian Phone:

I have obtained permission from all parents/guardians for minors present in the video and have submitted a completed contest permission form (PDF) (1 pp, 62K, about PDF) (answer "Yes" or "Not Applicable"):