Arts Expression Release Form
This agreement will grant Laury Rappaport. Ph.D., LMFT, REAT, ATR-BC and the Focusing and Expressive Arts Institute the right to reproduce the arts expression and associated information that you are submitting via electronic communication for the purpose(s) below.
I agree to allow Laury Rappaport and the Focusing and Expressive Arts Institute to use my arts expression and associated information for the following purpose(s):
I hereby grant the use of my arts expression and associated information as defined by the purposes above to Laury Rappaport and the Focusing and Expressive Arts Institute in perpetuity. I give express consent to the altering or editing of the aforementioned work for editorial purposes and waive the right to inspection or approval of the finished product. I attest that I have voluntarily provided my artwork in accordance with the agreed upon conditions in this release form. I acknowledge that once I sign and submit this form, I will have three (3) days to withdraw my consent.
Note: The information you submit on this form is protected and will be kept only for the Focusing and Expressive Arts Institute's private records. The name that will accompany your artwork is separate from this form and will follow your preference and anonymity choice established in the initial electronic communication.
Enter your full name: *
Email address: *
Electronic Signature: *
Your Arts Media Release Form has been successfully submitted. Thank you for your contribution to our community!
For questions, please email firstname.lastname@example.org.
An error occurred. Please check to make sure all required sections are filled out and try submitting the form again. If you need further help, please contact us for assistance.