Child's Name (as it should appear in print)
Child's Birthday (please include month, day and year)
The following information is for CPC use only and will not be published or disclosed in any way beyond CPC staff.
City, State and Zip
UPLOAD PHOTO HERE
File size not to exceed 2MB. Accepted images are JPGs, PNGs, PDFs, TIFs and GIFs.
CONSENT TO USE PHOTO
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By clicking this box, I am providing electronic signature that I am 18 years or older, or the parent/legal guardian of the child submitted in this entry. I hereby give permission to Coulee Parenting Connection to use my name and photographic likeness (or my child’s) in the magazine and on the website as a semi-finalist in the CPC Cover Model Search 2017. I understand that as a result of the use of my photo in the magazine, my photo may be used in advertising and marketing for Coulee Parenting Connection, including but not limited to other print media and television. I also understand that, as a semi-finalist, I will be a model for CPC and must conduct myself as such. This includes working with CPC staff and photographers to create cover concepts of the highest possible quality. IF I AM SUBMITTING A PROFESSIONAL PHOTO, I UNDERSTAND I MUST OBTAIN APPROPRIATE PERMISSION FROM THE PHOTOGRAPHER FOR USE ON CPC'S WEBSITE, AND THAT CPC IS NOT RESPONSIBLE FOR COPYRIGHT INFRINGEMENT OF PHOTOS KNOWINGLY SUBMITTED WITHOUT PROPER APPROVAL.
Name of person paying
Contest fee amount: (please fill in $5)
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