Safe Prom Entry and Release Form - Lakeland Regional Medical ...

Safe Prom Entry and Release Form
The name of the high school and principal should be listed on this release form. In addition,
names, addresses, phone numbers and email addresses must be provided for all those involved
in the production/submission of the video. Lakeland Regional Medical Center (LRMC) will not
display or release any addresses, phone numbers or email addresses in connection with the
submission (except to the extent it is contained in the submission.)
All contest rules must be followed and LRMC retains the right to determine if the submitted
entries comply with said rules.
The participant understands that the use of the submission is completely at the discretion of
LRMC. LRMC will not return the submission and has no obligation to retain it. Therefore, the
participant understands that she/he needs to keep a copy of whatever is sent. LRMC will not
make any payment to the participant or any third party for usage of the video.
Each submission release must be signed and returned with the video in order for the video to
be judged. The submission must be postmarked by April 12, 2013. All questions should be
emailed to:
Brittany.taylor@lrmc.com
School:
Principal:
Teacher:
Participant’s name address, phone numbers and email address:
Participant’s signature: ______________________________ Date_______
Parent’s name:
Parent’s signature: __________________________________Date _______

Directions for Submitting Safe Prom
Video Contest
1. Videos must be in Video DVD format. Video must be no shorter than
60 seconds, and no longer than 3 minutes.
2. Entries and all release forms must be postmarked by Friday, April 12,
2013 and mailed to:
Lakeland Regional Medical Center
1324 Lakeland Hills Blvd
Lakeland, FL 33805
Attn: Trauma Services Department, Brittany Taylor
3. The video must accompany ALL of the Entry and Release forms for
who is featured in the video. It must be signed by the participant, and
if the participant/student is a minor it must be signed by the student’s
parent/guardian.