1. Provide the following contact information. This name will be considered the primary contact and all communication will be directed to this person. 

   Name, FIRST
   Name, LAST
   AGE (required if you are 17 or younger)
   Street Address
   City
   State	(You must be an Arizona resident to enter.)
   Zip Code
   Email Address
   Home (at least one phone # is required)
   Cell (optional)

2. You must agree to contest rules and regulations in order to enter. Read the following statement and mark either Yes or No (if No, then you will not be able to participate.)

   Agreement to Contest Rules & Regulations:

   By checking the "yes" box below, I state that I have read the contest rules & regulations and I agree to all terms of the Green Arizona Youtube Contest. 

    

   Yes, I agree
   No, I do not agree
   

3. If more than one person will be participating in creating this video, list each name, including phone and email for each person.

   
   

4. If you have already selected a video topic, please enter here (not required). If you change your mind, you can select a new topic at any time. 

    

   Parental Permission:
   

5. Parent or Guardian Permission Slip: If the primary contact (above) is 17 or younger, a parent or guardian must provide permission.

   Name of parent or guardian
   Street Address
   Address (cont.)
   City
   State
   Zip Code
   Country
   Home or Cell (at least one phone # is required)
   Work (optional)
   E-mail

6. I declare that I am the parent or guardian of the minor, named above, and hereby give my permission to participate. I will be involved in the selection of an age-appropriate video topic and I will provide oversight as needed to ensure safety. Check Yes to agree. (You must check yes in order to participate.)

   Yes, I give permission.  (If the Alliance cannot verify Parental/Guardian authorization, your entry will be disqualified.)
   No, I do not give permission.
   

    NOTE:  If your entry is one of the contest finalist, the Alliance will contact your parental/guardian to verify permission by phone or in writing. If the information you provided above is not correct, the entry will be disqualified. 

    

THAT'S ALL -- just click "submit form" below to register your entry!

After you click "submit form" you will be directed to a Confirmation Page showing the information you entered above.  If you need to make any corrections, you can re-submit a new form. Forms are date-stamped and we will use only your most recent registration.