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* 1. Choose a category to enter

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* 2. First Name

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* 3. Last Name

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* 4. Phone Number (including area code)

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* 5. Email Address

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* 6. Title of video posted on YouTube

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* 7. Date video was posted to YouTube (MM/DD/YYYY)

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* 8. URL (or link) to your video on YouTube

By clicking the submit button below, I certify that I am the creator of the original video titled above;
have read and agreed to the contest rules; and that I grant the Arizona Department of Health
Services and its agents a royalty-free license to copy, distribute, modify, display,and perform
publicly and otherwise use, and authorize others to use my video for any educational purpose
throughout the world and in any media.

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