Permission to Use name and Likeness
aUtHor seCtion
Column A: Work in Which Name(s)
and/or Likeness(es) will Appear
Tentative Title:
Author(s):
Publisher:
NASW Press
Tentative Publication Date:
Column B: Individuals to be Featured in the Work Specified in Column A
(Please type or print. If necessary, please continue the list on the back of this form.)
First and Last Name (Pseudonym, if any):
First and Last Name (Pseudonym, if any):
First and Last Name (Pseudonym, if any):
First and Last Name (Pseudonym, if any):
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 publi-
cation 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, contin-
ued 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.
