More About - Back to Home
 
Counseling Center - Healing Through Creativity Submission Form
By submitting your art works, you agree to give permission to Pei-Yi Lin, Ph.D and the Counseling Center to use my creative art work for the Sexual Assault Awareness Month and publicity, educational and training presentations, or other similar uses. If my submitted work is used for these purposes, I waive all rights to remuneration for the uses listed above. For any other purpose I understand that I would be contacted for permission.

Items with an * indicate a required field.
Artist's Name *
Date *    
Email *
Phone
If necessary, may we leave a message?  Yes
  No
Do you prefer to be contacted by:  Email
  Phone
Please check one of the following:  You may use my name
  I want to remain anonymous
 
Creative Work Submission #1
Medium
Dimensions of Art
Title of Artwork
Description of Artwork
 
Creative Work Submission #2
Medium
Dimensions of Art
Title of Artwork
Description of Artwork