PERMISSION TO PUBLISH

If you are submitting an article, poem, or artwork to the Journal, please fill out this form and e-mail it immediately to editor@survivorship.org. You may, rather than e-mailing the form, mail it to the address below. Print out one copy for your records. 
If you have any questions, please contact us at editor@survivorship.org

SURVIVORSHIP
Family Justice Center
470 27th Street
Oakland, CA 94612

Title of piece________________________________________________
Pen name or name of author:___________________________________
Address: ___________________________________________________
__________________________________________________________
City _______________________________________________________
State _____________________________Zip______________________
e-mail _____________________________________________________

Has this piece been published before? Yes ____     No ____
If so, when and where? _______________________________________
__________________________________________________________
If already published, do you still own copyright to this piece? ____ Yes     ____ No
This piece is my own original work and I own the copyright to it. By signing this document, I retain the copyright and grant Survivorship the right to publish it in the Journal or Survivorship Notes and reprint it in both hard copy and electronic form.
I also give Survivorship the right to publish it in the public section of the website (www.survivorship.org).  ____ Yes     ____  No 

I hereby indemnify and hold harmless Survivorship and any person or entity connected with it against any legal action brought because of the publication of this piece.
Signature: ___________________________________________________
Date: _______________________________________________________