<p>Green Flicks Illawarra short film competition</p><p>Entry form – individuals All fields are compulsory. Read the Conditions of Entry before you fill out this form. A Consent to Participate form will need to be submitted for each participant featured in the film.</p><p>Primary contact details Yourself, a teacher, parent or guardian.</p><p>Full name: Click or tap here to enter text.</p><p>Street address: Click or tap here to enter text.</p><p>Phone number: Click or tap here to enter text.</p><p>Email: Click or tap here to enter text.</p><p>Date of birth: Click or tap here to enter text.</p><p>Age category Based on your age at 8 September 2017. 12–14 years ☐ 15–17 years ☐ 18 –24 years ☐</p><p>About your film</p><p>Film title: Click or tap here to enter text.</p><p>Length of film: Click or tap here to enter text. Name of your primary school or high school/s for all group members (if applicable): Click or tap here to enter text. Short description of your film (no more than 200 words): Click or tap here to enter text. APRA/AMCOS licence number if applicable: Click or tap here to enter text. Confirmation</p><p>☐ I have read and understood the Terms and Conditions of Entry and confirm that: </p><p>1. my entry complies with the Terms and Conditions of Entry 2. my parent/legal guardian has provided consent for me to submit this entry (if under 18). Note: If a parent or guardian has provided consent to enter, electronic submissions must be sent from the parent or guardian’s own e-mail address to confirm the reliability of this consent 3. all film participants’ consent has been obtained as per Clause 13 in the Terms and Conditions. </p><p>Signed (insert digital signature or type name): Click here to enter text.</p><p>Date: Click or tap to enter a date.</p><p>Office of Environment and Heritage, 59 Goulburn Street, Sydney South NSW 2000 Phone: 131 555 (environment information and publications requests) Email: [email protected]; Website: www.environment.nsw.gov.au OEH 2017/0262; June 2017.</p><p>2 [Publication Title]</p>