Name & Address

First Name:
Last Name:
Street:
City:
State:
Zip:
Email:

Photo Information

Photo 1:
Date Taken:
Location:
Title:

Photo 2:
Date Taken:
Location:
Title:

Photo 3:
Date Taken:
Location:
Title:

I certify that (1) I have read and agree to the 5th Annual Mattie Kelly Environmental Institute's Photo Contest Official Rules (Official Rules can be obtained at http://www.mattiekellyinstitute.org); (2) I am properly entering this Contest and complying in all respects with the Official Rules; and (3) I am not a Mattie M. Kelly Cultural & Environmental Institute Committee member or an immediate family member of any employee or Committee member. I represent and warrant that (1) I own all rights, title, and interest in and to the photos attached to this entry form ("Photo"), (2) the Photos are my original work, (3) the Photos do not infringe the intellectual property or other rights of any other person or entity, (4) I have all of the necessary rights and authority to submit the Photos, and (5) that I am an amateur photographer as defined in the contest rules. I understand that by submitting these Photos, I am granting the Mattie M. Kelly Cultural & Environmental Institute a limited license to publish and display the Photos, along with my name and information about the Photos, on organizational websites, without further compensation, and to make copies of the Photo for archival and organizational promotional purposes, including the sale and distribution of a 2013 calendar to be composed of contest photographs. I understand that submitted Photos will not be returned and will become the property of Northwest Florida State College.

I give Northwest Florida State College (NWFSC) permission to use my photograph(s) and to identify me by name, if deemed appropriate by the college, in all forms, manner and media, including but not limited to, display, illustration, advertising, promotion, electronic transmission, promotion for other college purposes. For these purposes, I relinquish my personal rights of privacy under the Family Educational Rights and Privacy Laws and release NWFSC from any liability for the aforesaid use.

I understand that said photograph(s) may be used in the publication of a calendar. I understand that I will retain ownership of the work itself and all rights to its publication. I am only granting NWFSC rights to publish this work and my name in this calendar free of charge, now or at any time in the future.

Name:
Date:

Minor Applicant?

A parent granting permission to participate for a person who is under 18 years of age must complete the following:

"I, , of , the parent of do hereby agree to all the provisions of the above release on behalf of my son/daughter."

Parent Name:
Date:

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© 2012 Mattie Kelly Environmental Institute
at Northwest Florida State College