Name of Parent and/or Guardian *

First Name

Last Name

Parent's and/or Guardian's Phone Number *

(###)

###

####

Address *

(This will only be used to mail winners their prizes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Youth's Name *

First Name

Last Name

Youth's Cell Phone Number *

(###)

###

####

I give the Hold On Campaign for Suicide Prevention permission to post my creative work on their website. *

Yes

No

I give the Hold On Campaign for Suicide Prevention permission to share my work with national and international suicide prevention organizations *

Yes

No

I give the Hold On Campaign for Suicide Prevention permission to share photographs of the youth on our website, social media, and other print/online media *

Yes

No

I am interested in being interviewed and having my creative work published in the media if I am one of the top 10 finalists. *

Yes

No

I would like my name displayed on my creative work as: *

My age and full name

My age, first name and first initial of my last name