Participant Form and Parental Permission Form

Each participant must fill out a separate form.

Participant's Name: _________________________________________________________

Address: _________________________________________________________________

City, State, Zip:____________________________________________________________

Participant's Farm Bureau Membership Number:____________________________________

Name of Video being submitted:_________________________________________________

Organization/Team Name (if submitting as a group):__________________________________

Short Description of Video:

Participant Signature:_________________________

I agree to all of the rules of the contest and hereby submit my video to Kansas Farm Bureau.

Parent/Guardian Signature (if participant is a minor):________________________

I hereby grant my child permission to participate in the Kansas Farm Bureau Your Farm Video Contest.

Must be postmarked by December 31, 2010           

Mail all forms and the final video on CD or DVD to:

Young Farmers & Ranchers

YouTube Contest

Kansas Farm Bureau

2627 KFB Plaza

Manhattan, KS 66503