Student Name: __________________________________

Course Name, Number, Semester, and Year: _______________________________________

Description of Materials To Be Used (Be specific as to title, length, editorial changes that will be made, etc.) :

I would like to keep a copy of the work described above to use in future class materials as a sample of the work students do in this class. If you are willing to let me use your work, please sign your legal name below and print your permanent address and the date in the spaces provided. Staple this form to a clean copy of your work when you return it to me. Please note that I may not be able to return the work to you.

Please sign your legal name. ________________________________________________

PRINT your permanent (not school) address: _______________________________________________________________

Today’s Date: _____________________________________________________

Thank you for your cooperation.

_____________________________________________

Signature of Faculty Member