<p> 2016 Long Term Care Photo Contest Submission Form</p><p>CONTACT INFORMATION</p><p>Name: </p><p>Member Facility/Organization Name: </p><p>Address: </p><p>City: State: Zip: </p><p>Phone Number: E-mail: </p><p>ENTRY INFORMATION</p><p>Photo Taken By: </p><p>Photo Title: </p><p>Narrative/Description of Photo (Maximum 30 words): </p><p>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.</p><p>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. </p><p>Questions? Contact Steve Mould at OHCA ([email protected], 614-307-9235) </p>