The following form must accompany each writing model you submit. Please fill in the boxes below; then print out the form, sign it, and have your parent or guardian do the same. Mail this agreement with your model to

Write Source
PO Box 460
Burlington, WI 53105

or fax it to
262-763-2651

I, , choose to submit to Write Source Educational Development House, a division of The Sebranek Group, a copy of an original writing model entitled .

I agree to release the nonexclusive world publication rights to my writing for use by Great Source Education Group, a division of Houghton Mifflin Company. I understand that my writing may be edited to suit the project in which it is published, and that an acknowledgement may or may not accompany the model. I also understand that Great Source Education Group, a division of Houghton Mifflin Company, may reproduce, print, and publish the model in any form, format, or media, including the Internet and all digital media.

Name: Grade:

Street Address:

City: State: ZIP:

Date:

Student Signature:

_____________________________________________________

Parent or Guardian Signature:

_____________________________________________________