2012 Crash Course Teen Driving Summit Contest Statement of Eligibility

Transcription

1 2012 Crash Course Teen Driving Summit Contest Statement of Eligibility All forms must be returned to Kathy Monroe, MD at or by fax: (205) by October 26, 2012 at 11:59 p.m. Central Time or we will select an alternate winner, per contest rules. Contact Information First and Last Name of Student Team Leader: Team Leader Address: First and Last Name of Faculty Sponsor: Title of Faculty Sponsor: Faculty Phone Number (with area code): ( ) Faculty Address: School Information Please provide the following information regarding your school. Grants can only be provided to 501(c)(3) taxexempt or municipal organizations (not individuals). The project funding will be sent directly to the winner s high school to the attention of the Faculty sponsor listed above. 1. High School Name: 2. School Street Address (street number, city, state and zip code): 3. School Phone Number (with area code): ( ) 4. School Web site (if any): 1

2 Please Check One: Municipal Organization School which qualifies as a charitable organization under Section 501(c)(3) of the Internal Revenue Code The school must attach a copy of U.S. Department of Treasury letter of qualification as under Section 501(c)(3) to this statement of eligibility) 2

3 2009 Crash Course Teen Driving Summit Contest Affidavit of Eligibility/Liability & Publicity Release SCHOOL INFORMATION STATE OF COUNTY OF Name of winning school ( School ): Authorized representative of School: (print/type name of authorized representative of School), I, as an authorized representative of School, being duly sworn, say: I am employed at (include School name and address): Phone: Work: ( ) - Home (optional): ( ) - I am submitting this Affidavit of Eligibility/Liability & Publicity Release ( Affidavit & Release ) with the understanding that it will be used to confirm the School s eligibility in the Crash Course Teen Driving Summit Contest (the Promotion ), sponsored by The Allstate Foundation (the Sponsor ). I represent that I am ready, able and willing to partake in any media opportunities (e.g., interviews, photos, sound bites, video footage, etc.) surrounding the Promotion, and that I have the right to enter into this Affidavit & Release. I also grant Sponsor and its designees the right to use my name, voice, picture or other likeness for advertising, promotional and other purposes as determined by Sponsor and its designees in any and all media now or hereafter known throughout the world in perpetuity, without further approval, notification or compensation, unless prohibited by law. I further represent that I have committed no fraud or deception in entering the Promotion or in claiming any prize awarded to the School. As an authorized representative of the School, I represent that: the School qualifies for tax-deductible contributions as a charitable organization under Section 501(c)(3) of the Internal Revenue Code, or is a municipal organization. the prize money awarded will not be used to contribute to fund-raising projects (such as buying tickets to an event or supporting a walk-a-thon). 3

4 the School, including its employees and agents, will allow The Allstate Foundation and Allstate Insurance Company and their affiliates and/or agents (collectively Allstate ) to use the School s name, and biographic or other specific information in connection with this promotion and award. The School will allow The Allstate Foundation and Allstate Insurance Company to promote the project(s) and team participants to local media outlets (including interviews with students), media and marketing materials such as press kits for media, Allstate Foundation newsletters, reports and Web sites. In addition, I represent that as of the date of this Affidavit/Release, I am not and was not an employee (or an immediate family member (spouse, mother, father, sister, brother, ward, daughter or son) or household member (whether or not related) of an employee) of The Allstate Foundation, The Allstate Corporation, or their respective parents, affiliates, subsidiaries, divisions, advertising or promotional agencies, contest processors, or web masters and web suppliers. The School acknowledges and hereby releases and hold harmless Sponsor, Allstate Insurance Company, and their respective parents, affiliated and subsidiary companies, divisions, promotion partners, advertising and promotional agencies, contest processors, web masters and web suppliers, and each of their officers, directors, employees and agents (collectively, the Released Parties ) from and against any and all claims, actions, and/or liability for any loss, injuries and/or damages (including, without limitation, any death or disability) sustained in connection with use of a prize or related to School s participation in the Promotion. It is understood and agreed that this is a complete RELEASE and DISCHARGE of all claims and rights of the undersigned against the Released Parties, and that no action will be taken by or on behalf of the undersigned with respect to any such rights; it being understood that this release shall be binding upon the parents, guardians, heirs, executors, and administrators of the undersigned. (Authorized School Representative) (Date) Sworn to and subscribed before me this day of, NOTARY PUBLIC 4

5 2009 Crash Course Teen Driving Summit Contest Statement of Eligibility STUDENT TEAM LEADER STATE OF COUNTY OF I,, being duly sworn, say: (Student Team Leader Name) I am years old. My date of birth is / /19 I reside at (include city, state, and zip code): Phone: Home ( ) - Cell ( ) - I am submitting this Affidavit & Release with the understanding that it will be used to confirm my eligibility in the Crash Course Teen Driving Summit Contest (the Promotion ), sponsored by The Allstate Foundation (the Sponsor ). I represent that I understand and have fully complied with the Terms and Conditions for the Crash Course Teen Driving Summit Contest ( Contest Terms and Conditions ) and that I have committed no fraud or deception in entering the Promotion or in claiming any prize awarded to me. I further represent that I am a permanent legal resident of one of the fifty (50) United States or District of Columbia; between the age of 13 and 18 years of age at the time of registration; and ready, able and willing to partake in any media opportunities (e.g., interviews, photos, sound bites, video footage, etc.) surrounding the Promotion, and that I have the right to enter into this Agreement. In addition, I represent that as of the date I entered the Promotion and the date of this Affidavit/Release, I am not and was not an employee (or an immediate family member (spouse, mother, father, sister, brother, ward, daughter or son) or household member (whether or not related) of an employee) of The Allstate Foundation, The Allstate Corporation, or their respective parents, affiliates, subsidiaries, divisions, advertising or promotional agencies, contest processors, or web masters and web suppliers. 5

6 I grant Sponsor and its designees the right to use my name, voice, picture or other likeness for advertising, promotional and other purposes as determined by Sponsor and its designees in any and all media now or hereafter known throughout the world in perpetuity, without further approval, notification or compensation, unless prohibited by law. I understand and acknowledge and hereby release and hold harmless Sponsor, Allstate Insurance Company, and their respective parents, affiliated and subsidiary companies, divisions, promotion partners, advertising and promotional agencies, contest processors, web masters and web suppliers, and each of their officers, directors, employees and agents (collectively, the Released Parties ) from and against any and all claims, actions, and/or liability for any loss, injuries and/or damages (including, without limitation, any death or disability) sustained in connection with use of a prize or related to participation in the Promotion. I warrant and represent that I have the full right and power to enter into this Affidavit/Release, and that the terms of this document do not in any way conflict with any existing commitment on my part. I agree that this Affidavit/Release supersedes any prior understandings between myself and the Sponsor relating to the rights granted herein and no provision of this Affidavit/Release can be modified by any other instrument, invoice or document unless in writing and signed by the parties hereto. It is understood and agreed that this is a complete RELEASE and DISCHARGE of all claims and rights of the undersigned against the Released Parties, and that no action will be taken by or on behalf of the undersigned with respect to any such rights; it being understood that this release shall be binding upon the parents, guardians, heirs, executors, and administrators of the undersigned. (Student Team Leader Name) (Date) (Student Team Leader Signature) Signed: (Parent or guardian if above signatory is under 18) Sworn to and subscribed before me this day of, NOTARY PUBLIC 6