Permission to Use Name and Likeness

AUTHOR SECTION Column A: Work in Which Name(s) Column B: Individuals to be Featured in the Work Specified in Column A and/or Likeness(es) will Appear (Please type or print. If necessary, please continue the list on the back of this form.)

Tentative Title: First and Last Name (Pseudonym, if any):

First and Last Name (Pseudonym, if any): Author(s): First and Last Name (Pseudonym, if any):

Publisher: First and Last Name (Pseudonym, if any): NASW Press Tentative Publication Date: First and Last Name (Pseudonym, if any):

SECTION FOR FEATURED INDIVIDUAL(S) I hereby give NASW Press (hereinafter called the “Publisher”) permission to publish information about my minor child(ren) and/or me (listed in Column B above). This information includes names (unless otherwise indicated below), likenesses obtained by photography or illustration, and/or description of events or characteristics as provided by the author(s) listed in Column A above in the book or publication listed in Column A above (and any future revisions, editions, and formats). I release the author(s) and publisher listed in Column A above, singly and jointly, from any claims that I might have against them now or at a later date resulting from the publication of the book or publication listed in Column A above.

Please check if applicable: I request that (a) pseudonym(s) be substituted for the name(s) of the individual(s) listed in Column B above (and, if applicable, continued on the back of this form).

Please check only one: The individual(s) listed in Column B above (and, if applicable, continued on the back of this form) is/are: both me and minor children of whom I am the parent or legal guardian me minor children of whom I am the parent or legal guardian

Name (Please print): Signature:

Address:

Email Address: Telephone:

Date:

Please return this form to NASW Press, 750 First Street, NE, Suite 700, Washington, D.C. 20002-4241.