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Poetry Submission Form

______________________________________________
(Title)


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______________________________________________

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Poems can also be submitted on a separate page and attached. Be sure to fill out the form below for each submission.


Poet Information & Release Form

Poet's Name:  _________________________

Age:  _________________________

Address:  _________________________
_________________________

Tel No.  _________________________

Contact Person Name:  _________________________

Tel No.  _________________________

If you wish to be listed as anonymous in publications, check here: ________


By signing below, I understand that I am giving The AIDS Poetry Project unlimited rights to reproduce the above or attached poem in any print or electronic media form.


Parent/Guardian's signature:
(for children under 18)
_________________________

Poet's signature:
(for people 18 and over)
_________________________





  
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This article was provided by AIDS Poetry Project.
 

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