Ban the Box on College Applications: Video Campaign
Ban the Box on College Applications Video Campaign Submission Form

Speak your voice and tell people why you believe access to higher education for students during and after prison is important! Submit your video today!

Submission Deadline: October 1, 2017 at 5:00 p.m. EST

Facts:
Higher education transforms lives, reduces recidivism, and strengthens communities.
Only 3% of incarcerated individuals have access to higher education in prisons.
Many colleges and universities use criminal history screenings in admissions process.

For more information and instructions please visit https://docs.google.com/document/d/1txos0Bm5UVpp9E3Kwiz8wRVt7yVfFAWJgAHE3aiIKkk/edit?usp=sharing

Contact Stan Andrisse, MBA, PhD, Executive Director, From Prison Cells to PhD, Inc. with any questions or comments: sandris2@jhmi.edu or 314-922-0198.

Thank you for participating!

Email address *
First Name *
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Last Name *
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Phone Number (optional)
Your answer
State of Residence *
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Affiliation (School, University, Company, ect.) *
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Title *
How did you hear about this campaign *
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Link to YouTube video. *
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Is there anything else you'd like to mention?
Your answer
CONSENT FORM: Photo/Video Release: AUTHORIZATION TO USE PHOTOGRAPHS AND/OR AUDIO-VISUAL. I hereby authorize College and Community From Prison Cells to PhD, Inc. to use, reproduce, and/or publish photographs and/or video that may pertain to me— including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the organization’s Internet Web Page. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, the nonprofit may publish materials, use my name, photograph, and/or make reference to me in any manner that the Corporation deems appropriate in order to promote/publicize service opportunities. ***Checking yes below serves as your e-signature. *
Do you have anyone else featured in this video? If someone else is featured in the video, they must submit this consent form https://goo.gl/forms/ssPnZzjj2bo9EjjH3. *
A copy of your responses will be emailed to the address you provided.
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