Info Finder

Department Info

Be Tick Free Media Contest

Department of Behavioral & Community Health



"Be Tick Free!"

Dutchess County's 2016 Media Contest Submission Form

ALL Participants (Individuals and Group Members)
Must Submit this Form By 11:59pm March 11, 2016

Please complete the entire form.

Public Service Announcement Video Requirements
(check each box to indicate requirement has been met)
 720dpi or 1080dpi  Uploaded Video to YouTube
 30 or 60 seconds YouTube Link is Functional


 Individual Entry
 Group Entry (Designate lead and enter the Group's name below)

If Group, Name of Group: 


Name (First, Last):    Grade:

Street Address: 

City/Town/Village:   State:   Zip Code:


Teacher/Org. Leader Name:  

Teacher/Org. Leader Phone: 


Parent/Guardian Contact Information

Parent/Guardian Name: 

Home Phone: 


Work Phone:   Cell Phone: 

How did the student hear about the “Be Tick Free!” Media Contest?

(Max. No. of Characters: 500)


*Enter the following number in the box below before submitting your Contest Submission Form*


We verify the video submitted for consideration is the above mentioned student’s/group’s original creation for Dutchess County Department of Behavioral & Community Health’s 2016 “Be Tick Free!” Media Contest; and by submitting this video, we understand it may be displayed, reproduced, and promoted as part of the “Be Tick Free!” campaign and educational materials. All entries become the property of the Dutchess County Department of Behavioral & Community Health’s “Be Tick Free!” Campaign.



A. K. Vaidian, MD, MPH,Commissioner of Behavioral & Community Health A. K. Vaidian, MD, MPH
Commissioner of Behavioral & Community Health
Dutchess County Seal