Contest submission form

For those who prefer to fill out a paper form, you may download and print the 2020 DBTL Entry form instead.

 

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Student information

US Phone (###) ###-####

School Information

Constest submission

By the act of submitting my entry to your contest, I hereby authorize Kaiser Foundation, Kaiser Foundation Health Plan, Inc., The Permanente Medical Group, Inc., and any persons or entities acting at the request or discretion of Kaiser Permanente to display, distribute, reproduce, site, alter, and otherwise use the entry. I relinquish any and all ownership interest of or legal right related to the entry, and acknowledge that the entry is, after I submit it, the exclusive property of Kaiser Permanente.

(reminder: You may enter multiple times, but only 1 image per entry.)

Release / consent

By the act of submitting my entry to your contest, I hereby authorize Kaiser Foundation, Kaiser Foundation Health Plan, Inc., The Permanente Medical Group, Inc., and any persons or entities acting at the request or discretion of Kaiser Permanente to display, distribute, reproduce, site, alter, and otherwise use the entry. I relinquish any and all ownership interest of or legal right related to the entry, and acknowledge that the entry is, after I submit it, the exclusive property of Kaiser Permanente.

Student consent

Clear

Parent/Guardian consent

Clear