Release form

I, the licensor listed below (the “Licensor”), give my permission to include the specified poem or other written work listed below (the “Material”) in title of work listed below (the “Work”) to be published by Neopoet or one of its affiliated companies, or by a third-party company with a contractual relationship to Neopoet (“Neopoet”).

I grant Neopoet the right to use this Material
• in the Work and and in any related derivative and ancillary Works published by Neopoet or its licensees
• for worldwide distribution
• in all formats and platforms in any and all media now known or hereafter developed
• in all editions, for the life of those editions without restriction
• in all languages
• in advertisements and promotional materials for the Work.
I represent and warrant that (i) I am the sole owner of all copyright, trademark, and other intellectual property and proprietary rights in and to the Material, (ii) Neopoet's publication of the Material as authorized herein will not violate or infringe any copyright, trademark, or other intellectual property or proprietary right of any person or entity, and (iii) I am not a party to and the Material is not subject to any contract or arrangement which would conflict with my permission herein.

This Agreement shall be governed by, and construed in accordance with the laws of the State of New York.

In relation to any legal action or proceedings to enforce this Agreement or arising out of or in connection with this Agreement each of the parties irrevocably submits to the
exclusive jurisdiction of the courts in New York, New York.

Please indicate your agreement by signing and returning this form. In signing, you warrant you have no claim on ground of breach of confidence or on any ground in any legal system against Neopoet in respect of the publication of the Material.

*If the subject is under the age of 16, consent should be given by a parent or guardian and the relationship to the subject indicated.

I/We hereby grant permission for the use of the material requested above.