CREATIVE SCHOLARSHIP

(Form must be completely lled and signed.)

DATE DATE OF BIRTH HIGH SCHOOL TELEPHONE EMAIL COUNSELOR PRINT NAME HOME ADDRESS

I hereby give my permission to the high school to release a high school transcript and the information below. I hereby give my permission to Gulf Coast Regional Blood Center (The Blood Center) to publish or promote the project I submitted to The Blood Center in competition to the Creative Scholarship Award. I  certify that I am a graduating senior for the current school year. I certify that I plan to attend a college or university.
APPLICANT SIGNATURE

MODEL RELEASE

I understand that my picture, voice and/or my photographic materials will be recorded electronically and/or photographically by Gulf Coast Regional Blood Center (The Blood Center) or an agent thereof. I grant The Blood Center irrevocable permission to use these audio, video, motion picture or photographic recordings of me for its own use or distribution at the sole discretion of The Blood Center. I understand that these may be released to the public by or through The Blood Center or have possible distribution by the news media, or in broadcast, print and/or internet media. I understand that my name may be used in connection with these materials. I waive all rights, interests or claims for payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information and education, and the furtherance of the mission and goals of The Blood Center or for other lawful purposes.
APPLICANT SIGNATURE

SEND COMPLETED APPLICATION POSTMARKED NO LATER THAN MARCH 1.

(Late submissions will not be considered.)
INCLUDE:

1  . This completed application form; 2. Official transcript sealed by school counselor; and 3. Your creative project/presentation in the form of a: Web page; Recorded song; or

Typed essay or blog entry; Short film or commercial video; Or any other creative media!

BY MAIL: Gulf Coast Regional Blood Center, Donor Recruitment

1400 La Concha Lane, Houston, TX 77054-1802

OR EMAIL: scholarship@giveblood.org (Include application and attachments.)

For more information, call (713) 791-6665 or visit giveblood.org/scholarship. (Employees of The Blood Center, its affiliates and their dependents are not eligible.)

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