Kidsregen.org Submission Form
Mail to: Kidsregen.org Submissions
611 Siegfriedale Road
Kutztown, PA 19530

1. Contact Information (please check)
___I am of full age ___I act as the parent/guardian of the child

Child's First Name: ______________________________________________

Child's Last Name Initial:______________Child's Age:_______ M ____ F____

Parent/Guardian’s First Name:________________ Last Name:____________

Parent/Guardian’s Email Address: ___________________________________

Parent/Guardian's Address: _______________________________________

City, State, Zip: _________________________________________________

Country:_______________________________________________________

Parent/Guardian’s Phone Number:___________________________________

2A. Complete this part if your child is submitting written material or artwork to Kidsregen.org:
Do we have your permission to use and re-use your child’s artwork, letters, stories, and questions for publication, re-publication, and archiving on Kidsregen.org?
Yes ____ No____

2B. Complete part 2B only if your child is submitting photographs to Kidsregen.org:
Do we have your permission to use and re-use photographs submitted by your child for publication, re-publication, and archiving on Kidsregen.org?
Yes____ No____

NOTE: We must also receive a signed Model Release Form for each person shown in photographs. If animals are shown, we must receive a signed release from each animal's owner.

3. I hereby consent to and grant to The Rodale Institute the absolute right and privilege to use, re-use, publish, and re-publish all submitted material and/or photograph(s) of myself, ___________and/or my child,___________ and/or my property, as indicated above, in whole or in part, including any testimonial submitted in connection with such photograph(s). I also consent to the use of my child’s first name and first initial of last name in connection with the aforesaid photograph(s) and submitted material(s). The rights granted herein shall extend to any purpose whatsoever, including but not limited to, the sale, publication, display, and exhibition thereof in editorial, promotion, advertising, trade, or otherwise and in any and all media now or hereafter known, including but not limited to: CD-Rom, electronic databases, print, worldwide web, and archival and/or data retrieval systems.

I hereby release and discharge The Rodale Institute from any and all claims arising out of or in connection with the use of the photograph(s), or other material submitted. I hereby state that I am of full age and have the right to contract in my own name, and in the name of my child or legal ward. I further acknowledge receipt of full consideration for the rights granted herein.

Please Print
Parent/Guardian’s Name:_________________________________________

Parent/Guardian’s Signature:______________________________________