River of Words ® Contest Entry Form

Note : If we can't read your handwriting, you can't win a prize and you won't get your Watershed Explorer Ò Certificate. So, please print carefully and use a pen!

Date: ______Please check one: I am entering as an Individual___ , OR, as part of aGroup/Class*____.

Name:_________________________ Email____________________ Age:____ Grade:___  Male: ___ Female: ___

Title of Submission:______________________________________________    Art:___Poem:__ (Check one)

If you submitted artwork, what medium did you use? (acrylic, pencil, pastel..?)___________________

*Note: If you are entering as part of a group you MUST indicate whether you are entering through your school, scout troop, summer camp, park district, library, or other organization below.

*NEW REQUIREMENT!* Teachers/Facilitators: You must include a typed list of the names of all entrants in your group, plus the total number of entrants!

School or Organization_____________________________________Last Day of Classes (M/D/Y)___________

School/Org Address__________________________________________ City____________________________

State_____Zip/Postal Code___________Country:_____________   School Phone _________________________

Teacher/Facilitator(s) First Name___________________ Last _______________________________________

Parent or Guardian's Name__________________________ Signature _________________________________

Home Address _____________________________________ City_____________________________________

State___ Zip/Postal Code__________   Country ______________ Home Phone_________________________

I hereby grant and assign to River of Words (ROW) the non-exclusive right and permission, in respect of the original writing, artwork or photos that I have submitted to River of Words, to use, re-use, publish, and re-publish, and otherwise reproduce, and display the same, individually or in conjunction with other original artwork, writing, photos, and video, in any and all media now or hereafter known throughout the world, for illustration, promotion, art, advertising, and trade, or any other purpose whatsoever; and to use my child's name to identify the author of the work in connection with my participation in the River of Words Program.   I understand that any use of this submitted work will include my child's name as its creator. I hereby release and discharge River of Words from any and all claims and demands arising out of or in connection with the use of the original artwork, writing, photos, and video, including without limitations any and all claims for libel or invasion of privacy.   In any of the winning categories, River of Words maintains the exclusive right to declare no winner and withhold prizes if no poem   or artwork   of merit is found. ROW assumes no responsibility for lost or damaged poetry or artwork. River of Words   may sell, assign, license, or otherwise transfer all rights granted to it hereunder.   This authorization and release shall also inure to the benefit of the successors, legal representatives, licensees, and assigns of River of Words. I have read the foregoing and fully understand the contents thereof.   This release shall be binding upon me and my heirs, legal representatives, and assigns.   I further release River of Words from any responsibility for injury incurred during the research or production of the original writing, artwork, photos and video.

I, _______________________________, being the parent or guardian of the above-named minor, hereby consent to and join in the foregoing release and consent on behalf of said minor.  

Pledge of Originality: I declare and avow that the poem(s) or art I am submitting to the River of Words Contest is my own original work.

Student's signature______________________________________________________________________________

River of Words, PO Box 4000-J, Berkeley, CA  94704 USA
Tel: 510-548-POEM (7636) · Fax: 510-548-2095 · Email: info@riverofwords.org· Website: www.riverofwords.org