It's Worth It! Photo or Video Submission Form

Name *

First Name Last Name

E-mail *

Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Upload Video *

Social Media Marketing Campaign Terms

Toparticipate in the It's Worth It campaign you must agree to the following terms and model release. By submitting your video or photo you understand and agree that Connecticut Breastfeeding Coalition and the Connecticut Department of Public Health may use, edit, alter images to support the video and print social marketing campaign to support breastfeeding.

Please submit a video discussing your personal story about why breastfeeding is worth it (including but not limited to: delivering in a Baby-Friendly hospital, skin-to-skin, rooming-in). Photos showing these themes are welcome and encouraged too. Please do not include people in photos that do not consent to this agreement.
Connecticut Breastfeeding Coalition retains the right to use or not use images as it sees fit.
We will not sell, lease. or rent your information.

Model Release Agreement

By submitting this video/photo and form on behalf of myself hereby consent to Connecticut Breastfeeding Coalition (CBC) and the Connecticut Department of Public Health (CT DPH) use and editing of the It’s Worth It! submission video/photo (the “video/photo”) for purposes of promoting public health through breastfeeding and associated hospital initiatives around breastfeeding (skin-to-skin, rooming-in, etc.) and/or consent to the use of your voice (actual and in text) and likeness in the It’s Worth It submission video.

Further, if your video submission is chosen as part of a final campaign, I agree to allow that video to be posted to the CBC’s and CT DPH’s websites and social media channels so that the public can benefit from the sharing of information. I also acknowledge that the CBC and CT DPH will edit the video for the above-identified purposes; I will not have the opportunity to review or inspect the edited video. It is agreed that the video or any portion thereof, edited or otherwise, shall be used exclusively by CBC or CT DPH and solely for purposes of promoting improvement in public health. It is further agreed that neither CBC nor CT DPH is required to provide any payment or other form of remuneration to me for use of the video or any portion thereof.

I am over 18 years of age and have read the foregoing and fully understand its meaning and sign this waiver (by clicking off agreement below) and release without qualification or reservation. I further acknowledge the receipt of good and valuable consideration for this waiver and release. I understand and agree to hold CBC and CT DPH, its employees, and agents, harmless from and against any claims, causes of action or liability whatsoever arising out of, during, or in connection with my participation in the video/photo campaign, and hereby release and waive CBC and CT DPH, its employees, and agents, from any and all such claims. In addition, I release CBC and CT DPH, its agents and employees and assignees from any and all claims, demands, and liabilities whatsoever in connection with the use or editing of the video.

*

I agree to all rules and guidelines I agree to the terms of the model release and use waiver I am at least 18 years old

Funding for the "It's Worth It" project and website was made possible in part by the Connecticut Department of Public Health, supported by funds from the Centers for Disease Control and Prevention under the State Public Health Actions Grant.