"This is Me" Video Submission Form

Please complete all fields.

1. Your YouTube Video URL:

2. Your Email Address:

3. Your Name:

4. You are 18 years of age or older:

5. Your Location:

6. Please select the topic(s) that best fit the theme of your video.

7. If "Other" selected above, please specify topic(s):

8. Please name your charity of choice:

9. This is Me Video Contest Rules:

• No Wellsphere and/or HealthCentral member account is necessary to enter or win. Having an account does not improve your chances of winning.

• You agree not to use profane language, violence, sex or personal attacks against people or organizations in your video.

• You agree not to violate any applicable laws, including intellectual property laws, and to not use brand names or logos other than Wellsphere's, HealthCentral's, and their affiliated brand names or logos in your "This is Me" video. You agree to indemnify Wellsphere and HealthCentral from any claim, demand, judgment, or other allegation arising from your violation of the contest rules, including any alleged violation of someone's trademark, copyright, or other legally protected interest in any way in your video. All contest submitters agree not to make any commercial use of those portions of their submissions that refer to Wellsphere or HealthCentral without prior written approval from Wellsphere and HealthCentral.

• To the extent that you have any direct or indirect interest in any product, treatment, organization or company that you discuss or display in your video, you MUST disclose the material terms of that interest in the video itself. Your video may not contain endorsement, solicitation, commercial, or similar content advocating for or against specific doctors, specific hospitals, specific health practitioners, specific nurses, specific health organizations, specific non-profit organizations, or specific commercial products in a manner that implies those entities' methods are fail proof or failure prone. Any endorsement or discussion of a product, treatment or company included in your video must comply with the FTC’s "Guides Concerning the Use of Endorsements and Testimonials in Advertising" (http://www.ftc.gov/os/2009/10/091005revisedendorsementguides.pdf ). The emphasis is to be on what worked or did not work for you.

• Video submissions must be done through the "This is Me" Video Contest submission form. All form fields are required to be completed.

• Video entries will be shown publicly on the "This is Me" Channel on YouTube, www.youtube.com/yourhealthstory, if accepted. Viewers will be able to participate through watching, commenting, and sharing.

• Your video material must be original content.

• Videos must be in the English language or subtitled in English if no narration is provided.

• Release forms for all of the people featured in your video should be obtained. You must provide Wellsphere with the forms if requested.

• You must be able to provide Wellsphere with an original video file if you win.

• Submitters are responsible for ensuring that their videos are in compliance with the legal and copyright laws of their state/province and country.

• The contest is open to any individual or groups, professional or amateur.

• Video submissions must be from those ages 18 or older.

10. Usage:

By entering the contest, you grant Wellsphere and HealthCentral a perpetual, royalty-free license to use, publish and display your video, in any media, in exchange for acknowledgment such as mention of your name and/or website link in the video title or in the end credits. You grant Wellsphere and HealthCentral permission to edit, modify, format, or adapt your video at their sole discretion. Except for the grand prize, donation to charity of choice top 3 prizes, and top 10 videos featured on website awarded to winners of "This is Me," no other compensation in any manner will be paid to any entrant of the video contest for the submission of your video in any manner. If you want to remove your video from the competition, you may do so by requesting Wellsphere delete your video from its competition at least 24 hours prior to the announcement of the winner on or about May 17, 2010. There is no limit on the number of videos someone may submit, but multiple submissions do not improve chances of winning.


We respect your privacy. The personal information you submit to Wellsphere on the entry form will only be used to contact you in the event you win the contest or if there is a question or issue regarding your video or its content, and is otherwise subject to the Wellsphere Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). We will not disclose, give, sell, or transfer any personally identifiable information about you to any third party without your consent, except as provided in our Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). As your video will be made available to the public, you should not include personal information about yourself or anyone else that you do not intend to share. All information collected on the entry form will be deleted at the conclusion of the contest. Wellsphere is using YouTube to host the videos for this contest. You are also subject to YouTube's use, privacy, cookie, and security provisions. Those provisions can be viewed at http://www.youtube-nocookie.com/t/privacy.

11. Comments (Optional):