Release Form

RELEASE FORM - "Still Waking To Tears" Permission is granted to Traci Nelson for use of the material(s) indicated, submitted and detailed on the release form, in the anthology by Traci Nelson titled Still Waking To Tears and for any subsidiary use, promotional use, future revisions, and future editions of the same. Traci Nelson obtains one-time rights, permission for use of the composition(s) for Still Waking To Tears and then the rights revert back to the creator.

I agree that my work or any portion of my work will be used with my name (as on release form) and state. I give permission to Traci Nelson to reproduce, and edit as she finds appropriate and necessary, my original, unpublished writing entitled (please give the name(s) of your composition(s)). If my work is edited, I understand that Traci Nelson will send me a copy of her proposed edited version of the below-mentioned composition(s) prior to publication of Still Waking To Tears. Editing is necessary in protecting the identities and organizations, please edit the names as outlined in submission guidelines. I will have no right of approval of or claim arising out of any use by Traci Nelson of my work(s).

You must include correct contact information along with your submission including, at a minimum, full name, phone number and address. Unused submissions will not be returned nor can be guaranteed that they will be destroyed and/or removed from our files. All contact information will remain confidential. Traci Nelson bears no liability for the similarity of your work, if any, to any other material appearing anywhere at any time. Please submit this form with your submission. (An individual release is needed for each piece of work.)

Release Form: Still Waking To Tears

Please print (in black or blue ink) or type all information:

Please circle the name you would like your piece credited to:

Credited with First Name

Credited with Full Name

Anonymously

If using your first or full name, please print name as you would like it to appear:

___________________________________________________________

Submission Title: _____________________________________________

Amount of Pages Attached: __________

Date of Loss: Month _______________ Year ______________

State where loss occurred:___________

Country where loss occurred:___________

Contact Information

Printed Name:

(first)______________________(last)_________________________

Street Address: ______________________________________________

City: _____________________ State: ________ Zip Code: ________

Phone #: ______________________________

Date of Birth: ____/____/______

E-Mail Address: _______________________________________________

I understand that I will receive no payment for my submission or the works that result from it. A percentage of proceeds of this book will be directly donated to various Victim/Survivor/Anti-Violence organizations. If I have an organization I support, I will forward their business information to Ms. Nelson for possible proceeds donation. If I have supplied my mailing address, and my submission is accepted, I will receive a complimentary copy of Still Waking To Tears upon publication. I will notify Ms. Nelson of any change of contact information. I have read and adhere to terms of the release form and submission guidelines.

I agree to the terms listed above: ____

Signature:___________________________________

Date: ____/____/______

Please send submission and completed release form to:

Traci Nelson, PO Box 30012, Elkins Park, PA 19027-30012