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CREATE!ZINE RELEASE FORM FOR TEEN: Name: _________________________ Last Name

_________________________ First Name

Address: ___________________________________ __________ Street Apt. # __________________ City Phone: (

______ State

_______________ Zip code

)________________ Date of Birth _______________

Email:_______________________________________________ I hereby certify that the work submitted to the Phoenix Public Library was created by me and is completely original.

___________________________________ Signature

___________ Date

This release form must be signed by the parent or legal guardian of participants under 18 years of age.

FOR PARENT OR GUARDIAN: I hereby grant the right to use the participant’s name, creative works, and visual image on the Phoenix Public Library or City of Phoenix website, in printed form as part of Create!Zine, and/or for library promotion, without recourse. This includes rights to use creative works produced by the participant in promotional, documentary or media coverage for promoting Phoenix Public Library programs. This release grants the Phoenix Public Library the right to use the name and likeness of the participant and/or creative works produced by the participant on the Library or City of Phoenix website, in printed form as part of Create!Zine, and/or for library promotion. ____________________________________________ Signature of parent or guardian

____________ Date

_____________________________________________________________ Parent/Legal Guardian name (print)



Create!zine