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KID'S NAME_______________________________________________________________________________________
Present Age_________ Date of Birth_____________ Age at Achievement_________ Date of Achievement______________
Achievement/Claim to Fame____________________________________________________________________________
Kid's Address________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story and photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Kid's Signature________________________________________________________Date____________________________
Present Age_________ Date of Birth_____________ Age at Achievement_________ Date of Achievement______________
Achievement/Claim to Fame____________________________________________________________________________
Kid's Address________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story and photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Kid's Signature________________________________________________________Date____________________________
PARENT'S / GUARDIAN'S NAME____________________________________________________________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story and photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Parent's / Guardian's Signature
(Required if nominee is now under 21)_____________________________________________Date____________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story and photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Parent's / Guardian's Signature
(Required if nominee is now under 21)_____________________________________________Date____________________
AUTHOR'S NAME__________________________________________________________________________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Author's Signature____________________________________________________________Date_____________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed story to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Author's Signature____________________________________________________________Date_____________________
ARTIST'S / PHOTOGRAPHER'S NAME_______________________________________________________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed artwork / photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Artist's / Photographer's Signature______________________________________________Date_____________________
Address_____________________________________________________________________________________________
E-mail____________________________Phone________________________Fax__________________________________
I grant permission for the enclosed artwork / photograph(s) to be published and displayed in The Kids Hall of Fame Project:
(Books, Magazines, Newsletters, Trading Cards, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.)
created by Victoria C. Nesnick
Artist's / Photographer's Signature______________________________________________Date_____________________
The Kids Hall of Fame
Executive Offices
Three Ibsen Court
Dix Hills, NY 11746
1 (631) 242-9105 phone
VictoriaNesnick@TheKidsHallofFame.com
© 2008 The Kids Hall of Fame. All rights reserved.
Executive Offices
Three Ibsen Court
Dix Hills, NY 11746
1 (631) 242-9105 phone
VictoriaNesnick@TheKidsHallofFame.com
© 2008 The Kids Hall of Fame. All rights reserved.