Form 0 CO Contest Submission Form

Dear Parents/Legal Guardian,

The U.S. Consumer Product Safety Commission is hosting a poster contest for middle school students as part of an outreach effort to raise awareness about the poisonous gas carbon monoxide (CO).

How to Enter

• Submit the contest entry on the Web at www.cpsc.gov/COcontest/.

• The entry must include a jpeg or pdf (no larger than 1 MB each) of both:

  • A completed Contest Submission and Parental Consent Form (attached) and

  • Poster on the dangers of CO in the home

• CPSC must receive entry no later than February 27, 2015.

Official Contest Rules

For more information on the contest, including the official contest rules and how to enter please visit www.cpsc.gov/COcontest/. You may contact the contest administrators at COcontest@cpsc.gov.

For Teachers

Teachers who wish to submit posters on behalf of their students must submit a completed Contest Submission and Parental Consent Form, signed by the child’s parent or guardian, for each child submitting a poster.

Children’s Online Privacy

CPSC requires verifiable parental consent before it collects, uses or discloses personal information about children under the age of 13. Parents or Guardians must complete the Contest Submission and Parental Consent Form. CPSC’s policies governing what information is collected from children, how CPSC uses the information and CPSC’s disclosure practices for the information are located at www.cpsc.gov/COcontest/.

Sincerely,

CPSC

U.S. Consumer Product Safety Commission

Children’s Carbon Monoxide Safety Poster Contest

CONTEST SUBMISSION AND PARENTAL CONSENT FORM

1. Child’s First and Last Name

__________________________________________________

Full Name - Print (hereinafter referred to as "the child")

2. Child’s Grade Level in School

____________________

(Contest open to children in grades 6, 7, or 8)

3. Child’s State of Residence

_____________________

4. Parent or Guardian’s First and Last Name

______________________________________________________

Full Name – Print (hereinafter referred to as "the Parent/Guardian")

5. Parent/Guardian’s Contact Information (We will only contact you if your child is a prize winner or if there is a question about your entry. CPSC does not share your contact information with any third parties.)

Mailing Address: _________________________________________

City, State, Zip Code: _____________________________________

Phone Number: __________________________________________

E-mail Address __________________________________________

6. If my child’s poster is selected as a winner, I understand that I must provide my child’s social security number to the U.S. Consumer Product Safety Commission to collect the contest prize money. Winners are responsible for any applicable federal, state or local taxes.

7. I reviewed the contest eligibility requirements at www.cpsc.gov/COcontest/ and affirm that my child is eligible to enter the contest.

8. I reviewed the official contest rules at www.cpsc.gov/COcontest/ and consent and agree to be bound by the rules, including but not limited to, the rules governing copyright, intellectual property licensing and limitation of liability.

9. I agree and consent to CPSC collecting the child’s information provided in this Contest Submission and Parental Consent Form. I reviewed CPSC’s policies governing what information is collected about my child, how CPSC uses the information and CPSC’s disclosure practices at www.cpsc.gov/COcontest/.

10. I agree and consent to CPSC publishing or posting my child’s poster (the contest submission) and the child’s first name, grade level, and state of residence.

___________________________________________ ____________

Signed (Parent /Guardian) Date

___________________________________________

Print Name (Parent /Guardian)