Poetry Submission Form

From AIDS Poetry Project

______________________________________________

(Title)

______________________________________________

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)	_________________________

Back to AIDS Poetry Project Workbook 2

This article was provided by AIDS Poetry Project.

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