P.O. Drawer 1030, New Iberia, Louisiana 70562-1030 USA

“ORIGINAL” Louisiana Hot Sauce Video Contest

Parent/Guardian Consent Form

Contestant’s Name___________________________________ Date of Birth___/___/___

Physical Address__________________________________________________________

City_____________________________ State___________ Zip Code________________

Home Phone_________________________ Cell Phone___________________________

E-mail address____________________________________________________________

YouTube URL___________________________________________________________

I ________________________ grant permission for _____________________________

(Parent/Guardian) (Entrant/Contestant)

to submit ___________________________________ in the “ORIGINAL” Louisiana Hot

(YouTube URL)

Sauce Video Contest. I confirm that I have viewed the video and read the “ORIGINAL”

Louisiana Hot Sauce Video Contest Terms and Conditions in its entirety and give full

consent for ___________________________ to participate in contest and for video to be

(Entrant/Contestant)

entered in said contest.

_____________________________ ________________

Parent/Guardian Signature Date

_____________________________ ________________

Entrant/Contestant Signature Date