PLEASE PROVIDE THE BELOW INFORMATION AND SUBMIT WITH UP TO 5 DIGITAL IMAGES (JPGs):
(Use a separate sheet as necessary)

Artist Name:		
Email:		
Phone number:
Website:		
Address:

IMAGE 1
Title:
Size:
Date:
Media:
Caption (up to 100 words – optional):

IMAGE 2
Title:
Size:
Date:
Media:
Caption (up to 100 words – optional):

IMAGE 3
Title:
Size:
Date:
Media:
Caption (up to 100 words – optional):

IMAGE 4
Title:
Size:
Date:
Media:
Caption (up to 100 words – optional):

IMAGE 5
Title:
Size:
Date:
Media:
Caption (up to 100 words – optional):

Briefly describe (250 words maximum) your art and activism in relationship to challenging stigma and building awareness around mental illness and/or substance use:



Signature ___________________________________		Date_______________________