Submission Form Question Title * 1. Participant Information Name(s): Company (optional): Birthdate: Address: City/Town: State/Province: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: County (e.g. Westchester): Email Address: Phone Number: OK Question Title * 2. Relationship to Make-A-Wish Hudson Valley (Check all that apply) Wish kid/alum Wish family member Volunteer Community Supporter Corporate Sponsor Donor Board Leadership Medical Partner Staff Vendor Other (please specify) OK Question Title * 3. Performance Title OK Question Title * 4. Performance Description (1-3 sentences): OK Question Title * 5. SUBMIT YOUR PHOTOA photo for each participant (or group of participants) is required for video submissions - upload a photo below: PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File SUBMIT YOUR PHOTOA photo for each participant (or group of participants) is required for video submissions - upload a photo below: OK Question Title OK SUBMIT YOUR VIDEO*REQUIRED* Every participant must upload a video of their performance on Dropbox (click here). OK Question Title * 6. I certify that:'I own or have acquired rights to use any and all materials submitted. By signing below, I grant Make-A-Wish Hudson Valley and Make-A-Wish America permission to upload my video to the Make-A-Wish Hudson Valley YouTube channel and to share my video and likeness without restriction through social media, digital marketing, and traditional media, both now and in the future. I understand that if my video is selected for the talent show, Make-A-Wish Hudson Valley will upload it to the Tiltify platform and create an account for me, generating a unique URL for my video that can be shared with the community.' Yes No A Parent/Guardian must type their name below if the entrant is under the age of 18 on the date signed. OK DONE
