Holt Graduate Submissions

I, the undersigned, hereby consent to the reproduction, use, and/or exhibition of the information I have provided below and my photograph, a photocopy of which is attached hereto, by Holt International Children’s Services, Inc. (“Holt”). I further release Holt from any and all claims for damages for libel, slander, invasion of privacy, or any other claim based on use of the above-described materials. The consideration for this release is other than money, the sufficiency and receipt of which is hereby acknowledged by the undersigned. Neither Holt nor anyone associated with Holt has made any promise of any other compensation in relation to this release. This release extends to the employees, agents, licensees, successors, and assignees of Holt.
Holt may use the above-described materials in the following manners: (please check boxes)

Photo Submission Form
Holt may use these materials in the following manners:
Holt International magazine print and online Holt's Website (www.holtinternational.org) All manner of media, including unrestricted use for purposes of education, publicity, advertising, trade, display, editorial, exhibits, fundraising, and art. I do further consent to the use of my photograph by any other organization designated by Holt International Children's Services, including any other publisher, periodical, agency or client, and such photograph(s) may be used for any of the following purposes without any limitations or reservations: advertising, trade, display, editorial, exhibits, fundraising, and art purposes.
Information about the Graduate
* indicates a required field .
*Name:
*Address:
*City:
*State:
*Zip:
*Phone Number:
*Email:
*Birth Country:
*File name of submitted photo:
If you have just graduated from high school, fill out this section:
High School Activities/Sports/Awards/Honors:
College Planning to Attend:
Location:
Major:
Plans if not Attending College:
If you have just graduated from college, fill out this section:
College:
Location:
Degree:
Major:
College Activities/Sports/Awards/Honors:
Career or other Plans:
Guardian's Consent
The undersigned represents that he/she is the parent and/or guardian of the graduate named above and represents that he/she has the legal authority to execute the preceding consent and release and hereby approves the preceding and waives any rights in the premises.
Name:
Spouse's Name:
Extra Copies of the Magazine
Name:
Address:
City:
State:
Zip:
I declare that I am more than 18 years old.

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