YouTube Scholarship Contest Entry Form

  1. First Name:*
  2. Middle:
  3. Last Name:*
  4. Mailing Address:*
  5. City:*
  6. State/Province:*
  7. Zip Code:*
  8. Country (if not US):
  9. Primary Telephone:
  10. Email Address:*
  11. Gender:
    Male
    Female
  12. Date of Birth:*
  13. Video Title:*
  14. Video URL:*
  15. I have read and understand the official contest rules. If under 18 years of age, my parent/legal guardian has given me consent to enter this contest. *
    I Agree
    I Disagree
  16. The video I am submitting does not contain any copyrighted, inappropriate, or otherwise prohibited content. *
    I Agree
    I Disagree
  17. I confirm I have completed an application for admission and plan to enroll/have enrolled at Ivy Tech for the Fall 2013 semester.*
    I Agree
    I Disagree