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“12 chapters project”

STORY RELEASE FORM

Instructions: Please review the contents of this Release, complete it, and return it to Kimberly Mahan,
27 Blackberry Lane, Appleton, Maine 04862. If you have any questions regarding the Release, please
email organikimberly@gmail.com Thanks for your involvement and support with this project!

All stories will remain anonymous and your name will not be published with your story or otherwise
released without your permission.

I, the undersigned _________________________________________ (please print your name) ("Applicant"),


grants to Kimberly Mahan, and to her licensees and assignees, (“Mahan”) irrevocable permission to use all and/or
part of my story tentatively entitled _________________________ (the “Work”) for all uses and purposes
including but not limited to educational, advertising, press, marketing and/or promotional activities in any
medium ("Granted rights"). Uses of the Work may include, but are not limited to, featuring the story on web
sites, in books, presenting the story at seminars, trainings, and conferences, and/or screening the story in film
festivals, classrooms, or community settings.

Applicant grants to Mahan the right to use, copy, modify, create derivative works from, perform, publicly display,
publish, distribute, and communicate the Work, or any portion thereof, for all uses and purposes.

Applicant agrees that the rights granted herein are irrevocable, worldwide, royalty-free and without a requirement
for any approval or attribution, and agree that Mahan may copyright the collective work of which my Work is a
part as well as any derivative work. Applicant represents and warrants that the Work is original and the sole
creation of the undersigned; and if not, that Applicant has written rights from any other rights holder consistent
with the rights herein granted to Mahan. Applicant further agrees that Mahan shall be the exclusive owner of all
right, title, and interest (including copyright, electronic, and distribution rights) in and to any materials created by
or on behalf of Mahan that utilizes all or any portion of my Work. Applicant shall indemnify Mahan against any
claims or actions brought by third parties and any and all damages, losses, expenses, including legal fees, incurred
by Mahan that relate to or arise from a breach of the statements and warranties made by Applicant in this Release.

The parties, intending to be legally bound, have been advised to consult legal advice, and have executed this
Agreement in duplicate as of the day and year first written below. This Release Form is effective as of February
14, 2011.

APPLICANT
KIMBERLY MAHAN

By:_______________________________ By:______________________________

Title:______________________________ Title:_____________________________

Date:______________________________ Date:_____________________________