Name *

First Name

Last Name

Address *

This will only be used to send prizes to the contest winners.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

Yes

No

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

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 the first initial of my last name