CCALAC Member Video Challenge Submission

Thank you for participating in the Video Challenge!

Please complete this form to receive your stipend. A copy of your organization's W9 form is required. If you have any questions, contact tburks@ccalac.org.

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* 1. Please enter your contact information

Name

Clinic/Organization

Email Address

Phone Number

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* 2. When did you post your video?

Date

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* 3. What is/are the social media handle(s) where your video is posted? For example: Instagram @ccalac and Twitter @ccalac. If you did not post the video to a specific network, leave the corresponding space blank.

Facebook

Instagram

TikTok

Twitter

YouTube

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* 4. What is your video theme?

Advocacy

COVID vaccine education

Highlight of clinic work or program

Other (please specify)

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* 5. How does the video increase patient knowledge/engagement, advance health center priorities, etc.?

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* 6. How helpful was "Lights, Camera, Action! Beginners Guide to Video Development" in creating your video?

Extremely helpful

Very helpful

Somewhat helpful

Not so helpful

Not at all helpful

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* 7. Please share any feedback you have about the video guide.

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* 8. To receive your stiped, please attach your organization’s W9 form.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File