Water for Life Entry Form

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					                          ‘Water for Life’: a Short Film Festival
                                       Entry Form
This form must be submitted with each film entry. All personal information will be kept confidential.

Title of the film:                                                               Duration:             min

Contact details: to be used only to let you know if you win, and to invite you to the film screenings

Full name                               :

Date of birth (DD-MMM-YYYY)             :

Address for correspondence              :

Email address                           :

Telephone number                        :

Copyright and legal permissions
I confirm that my contribution is my own original work, is not defamatory and does not infringe any laws,
that I have the right to give DeshTV and WaterAid permission to use it for the purposes specified. By
sharing my film with DeshTV and WaterAid, free of charge, permission to use the material in any way
they want; including adapting it for operational reasons, using it for education and/or research. Copyright
in my contribution will remain with me and this permission is not exclusive.

Signed:                                                                 Dated:

About you: The information you provide will be used by WaterAid to evaluate the success of ‘Water
for Life’. It will be treated in the strictest confidence. It will NOT be used to select or judge films.

► How did you hear about ‘Water for Life’?

► Had you heard about WaterAid before hearing about ‘Water for Life’?
       Yes          No

► What is your sex?           Male          Female

► What level of education do you have (please tick)?
      Post Secondary         Graduate (e.g. BSc, BA)            Postgraduate (e.g. MA, MSc, PhD)

► Are you professionally involved in any of the following (please tick all that apply)?
      Journalism             Education                 Filmmaking                 Development Work

        Please submit this form in HARD COPY along with your film to Desh Television Limited,
     Karnaphuli Media Point, 70 Shaheed Sangbadik Selina Parveen Sarak, Malibagh, Dhaka 1217

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