PSA submission form

Director's PSA Submission Form

The Academic Integrity PSA program provides Connecticut high school and college students the opportunity to promote the value of academic integrity. All collaborators must complete a Collaborator's Consent Form for their PSA to be accepted. Please submit this form no later than March 4th, 2019.

The following form is to be filled out by the student who directed the PSA. All other participating students must be listed in the "Collaborators" section below.

* Indicates required field

Student Director's Name *

First

Last

Grade *

School Name *

Faculty /Sponsor Name *

Student Director's Email *

Student Director's Phone Number *

Student Director's Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

PSA Title *

Your PSA's Google Drive Link *

Please have the title of your PSA reflect it's content.
PSAs with generic titles will be subject to editorial changes.

Collaborators

Please list the first and last names of all the students that contributed in the creation of your PSA.
If only one student created and produced the PSA, place NA in the required boxes below. If more than five
contributed, please email ethics@ethicsed.org with balance of names, roles and email addresses.

Collaborator 1 *

First

Last

Role *

Collaborator 1 Email *

Collaborator 2 *

First

Last

Role *

Collaborator 2 Email *

Collaborator 3 *

First

Last

Role *

Collaborator 3 Email *

Collaborator 4 *

First

Last

Role *

Collaborator 4 Email *

Collaborator 5 *

First

Last

Role *

Collaborator 5 Email *

Please choose one *

I am 18 years of age or older. I am less than 18 years of age, and have my parent or guardian's permission to upload and submit my Academic Integrity PSA.

If you are under 18 years of age, you must provide your parent or guardian's full name and email address for your PSA to enter the Academic Integrity PSA Contest.

Parent/Guardian Name *

Parent/Guardian Email *

Agreement & Consent *

If the submitted PSA is chosen as a statewide winner, I am willing and available to attend the Celebration Dinner on Wednesday, May 1st 2019 at no meal cost to me and two of my family members. I allow the School for Ethical Education to use any photograph taken at the Celebration event to publicize the contest in the future, as well as my first and last name if the submitted PSA is used for promotional material. I agree and consent to the full release of the digital PSA file to the School for Ethical Education. I recognize that my image, name and voice may be identifiable in this project and that this PSA may be posted across various online platforms. I understand my PSA becomes the property of SEE to be used for any educational purposes. I affirm that all the material in the PSA is my own original work and is not subject to any copyright restrictions. I agree to inform my other collaborators to complete their own Agreement & Consent form and understand our PSA scoring will not be ranked until all member complete the form.

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Ethics in action creates character

Director's PSA Submission Form

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