Video Journal Registration

Please complete and submit the form below. Items with an asterisk (*) are required.

First Name

Middle Name(s)

Last Name

Birthdate

YYYY

Parent/Guardian Name 1

Parent/Guardian Name 2

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Participant's Personal Email

Please enter the participant's personal email address, as applicable. This will only be used for in-school coordination of interview scheduling.

Participant's Mobile Phone

Please enter the participant's mobile phone number, as applicable. This will only be used for in-school coordination of interview scheduling.

The 5000 Days Project Ambassador Program (optional)

Students may audition to be a 5000 Days Project Ambassador (there are a limited number worldwide). Selection is based on a student's authenticity, honesty, and ability to articulate his or her feelings. With everyone’s mutual consent, the story may become part of a 5000 Days Project film or curriculum designed to help other kids. In this program, students are interviewed each year by Rick Stevenson or a member of the 5000 Days Project team. The cost is shared by the Project and parents, the latter of which pay an additional $1000 a year (to The 5000 Days Project) which includes the personal interview, some limited filming of the Child’s school activities, and an annual contribution toward a professionally-edited 5-12 minute film when the Child turns 18. Note: Scholarships based on need are available for this program.

Consider us for the Ambassador Program (optional)

RELEASE FORM

This Participation Agreement and Release (the “Agreement”) is entered into between the 5000 Days Project LLC doing business as The School of Life Project (the “Company”); the “Parent(s)”; and the “Student” (collectively referred to as the “Parties”). 1. The Video Diary Project The Company has invited the Student to participate in The 5000 Days Video Diary Project (the “Video Diary Project”). As part of the project, the Student will be provided an opportunity on an annual basis to film his/her thoughts in response to a series of questions prepared by the Company (the “Footage”). The Student will record the Footage once every year until he/she completes Grade Twelve (the “Recording Period”). The Footage will be filmed on a Company computer and held for the Student in confidence until the Student is nineteen (19) years old. Unless otherwise permitted in this Agreement or required by law, the Company will not provide the Footage to any person except the Student when the Student reaches the age of nineteen (19) years. 2. Collecting, Using and Accessing Personal Information All Footage will be held confidentially and in a secure manner by the School or Company and will not be reviewed or disclosed by the School or the Company to any person other than the Student, except as otherwise permitted in this Agreement or required by applicable law. Notwithstanding the foregoing, the Company reserves the right, and Parent/Student agrees to permit the Company to review the Footage for the purpose of collecting, compiling and disseminating de-identified information regarding the students participating in the StoryCatcher Project. No personally identifiable information of Student (as defined in OMB Memorandum M-07-16) will be used or disseminated by the Company. 3. Payment The Cost of Participation in the Video Diary Project is $100 per year and includes the computer interview, storage and any review consistent with this Agreement. 4. Consent and Revocation The Parent(s) and the Student consent to the Student’s participation in the Video Diary Project, as described above. The Parent and/or the Student may revoke consent to the Student’s continued participation in the Video Diary Project by providing written notice of this decision to the Company. If the Parent and/or Student revoke consent, that revocation is not retroactive; however, the Student’s participation in the Video Diary Project will end at the time of the revocation. In these circumstances, the Company will hold any existing Footage and deliver it to the Student when he/she reaches the age of nineteen (19) years. 5. Release and Waiver In exchange for the Student’s ability to participate in the Video Diary Project, the Parents hereby: WAIVE AND RELEASE the Company, its members, officers, directors and shareholders for any claims the Parents may have, of any kind or nature, arising out of the Student’s participation in the Video Diary Project or arising out of that handling, maintenance, disclosure, or use of the videos in which the Student appears. The Parties acknowledge that the authorized reviews of the Footage will be conducted on a random basis and the Company does not assume the responsibility of reviewing the Footage in its entirety, or at all, for the purpose of identifying existing or potential safety risks. The undersigned understands that this Release and Waiver is intended to be as broad and inclusive as is permitted by the laws of the State of Washington, and that if any portion of it is held to be invalid, they agree that the remaining terms shall continue to be in full legal force and effect. 6. Entire Agreement This Agreement constitutes the entire agreement between the Parties with respect to the Student’s participation in the Video Diary Project and cancels and supersedes any previous oral or written communications, representations, understandings or agreements between the Parties with respect to the same. 8.Enforcement In the event of an action arising out of this Agreement, the exclusive jurisdiction and venue of such an action shall be a court of appropriate jurisdiction located in King County, Washington state.

By checking the box below, you agree to the following:

• I am the parent or legal guardian of the above listed minor. • I agree to the terms and conditions of The 5000 Days Project Film Project listed above. • I agree to the special payment terms already communicated with The 5000 Days Project by email.

I agree to all of the above

Video Journal Registration

Stay Connected