Expressive Arts and Writing Release Form

This agreement will grant Laury Rappaport. Ph.D., MFT, REAT, ATR-BC and the Focusing and Expressive Arts Institute the right to reproduce your original writing/artwork with the conditions below.

I agree to allow Laury Rappaport and the Focusing and Expressive Arts Institute to use the following:

Check all boxes that apply to the form(s) of the artwork you are sharing:

I agree to allow Laury Rappaport and the Focusing and Expressive Arts Institute to use my art for the following purpose(s):

Please check all that apply.

Anonymity preference:

Please select one:

I hereby grant the use of my writing/artwork 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 work 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.

Enter your full name: *

Today's Date: *

Email Address: *

Phone number:

Your electronic signature: *

Our pledge:

I, Dr. Laury Rappaport of the Focusing and Expressive Arts Institute, agree to the conditions listed in this form in connection with the use of your writing/artwork. I, and the Focusing and Expressive Arts Institute, agree to protect your confidentiality by not using your name in the presentation of your artwork if you stated that you want to remain anonymous. If you selected the option to include your name with your writing/artwork, I, and the Focusing and Expressive Arts Institute will include the preferred name as you have written above.

Signature:

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Your Arts Media Release Form has been successfully submitted. Thank you for your contribution to our community!