Video Contest Submission Form

Fill Out the Form Below – All fields are required

**THIS FORM MUST BE SUBMITTED BEFORE YOUR VIDEO MAY BE UPLOADED TO FACEBOOK.COM**

  • BY CLICKING THE "I ACCEPT" BUTTON BELOW, I AGREE ON BEHALF OF MY CHILD AS FOLLOWS:

    I, the undersigned parent or legal guardian request that my child be allowed to participate in the National Poison Prevention Week Video Contest.

    Read full agreement.