2016 Long Term Care Photo Contest Submission Form

CONTACT INFORMATION

Member Facility/Organization Name:

Address:

City: State: Zip:

Phone Number: E-mail:

ENTRY INFORMATION

Photo Taken By:

Photo Title:

Narrative/Description of Photo (Maximum 30 words):

ENTRY REQUIREMENTS  Entries must be submitted by an OHCA/OCAL/OCID member facility or Associate Member; no more than 1 entry per facility  Photos must be in high definition digital (JPEG, GIF, TIFF) format. Color and black and white images will be accepted.  Entries should represent an aspect of daily life in long term care, such as resident/staff interactions, activities, services, therapy and events. Resident portraits will also be accepted.  An entry form is required for each photograph.  Photo releases must be submitted for each individual pictured.  The member facility is responsible for obtaining and keeping on record an appropriate HIPAA authorization for each individual.

SUBMISSIONS  Submit entries to [email protected]  Attach the Photo Submission Form for each entry, and a Photo Release Form for each individual pictured  Complete entries must be received no later than October 15, 2016.

Questions? Contact Steve Mould at OHCA ([email protected], 614-307-9235)