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E M P O W E R M E N T


empowermentcouple

EMPOWERMENT

All submissions are Automatically Entered in a

$100 Drawing


Story Categories:
• Cyber Bullying
• Date Rape
• Creating A Positive Attitude
• Dating Violence
• Sexual Assault

• Depression
• Bullying
• Anger
• Building Self-confidence/esteem
• Emotions & More

Poem Categories:
• Self-Protection
• Motivational
• Positive Attitude
• Emotions

MAKE A DIFFERENCE

TEENS 13-19

LEARN HOW YOU CAN BE A PART OF THIS UPCOMING BOOK

 

We are looking for true heartfelt experiences to be submitted for possible entry in the upcoming Lila Reyna book "EMPOWERMENT" Teen To Teen Experiences of Self Protection. Although it can be difficult to share personal experiences, remember that this could possibly help someone who has experienced something similar or help prevent a harmful situation from occurring. No real names will be used in the book stories and information given is confidential, and only used for this book. Stories can be of any length. Misspellings and editing will be handled for you.

You may write your true experience down in a free form story or use these questions as a guideline.

1. How did this experience change your life, your perceptions,or your feelings?
2.What did you learn from your experience?
3.What advice would you give others in a similar situation?
4. How have you grown from your experience and continued to remain positive?
5. What resources, people, or things, helped you survive during and/or after your experience?
6. In what way did your experience effect your family or friends?
7. What does "having a poistive attitude" mean to you? How has having a positive attitude helped you?
8. If you could tell the whole world something, what would you say?

  • Submit your true personal experience/story, or original poem below
  • No real names will be used in the final book stories
  • All information is confidential
  • All submissions are automatically entered in a $100 drawing
  • Deadline for submissions and drawing entry is March 15, 2010
  • You will be notified personally from author Lila Reyna if your submission is chosen

You must me a registered member to make a submission. Please sign in or register here.

Submission Form

 
 
 
 
If under 18 years of age, please submit legal name of Guardian (First, Middle, Last) Minors are also required to fill out and return a release form available at the bottom of this page.
 
Guardian name :: First, Middle, Last
 
 
Full Mailing Address :: Number, Street Name City, State, ZIP
 
Phone Number :: 803-555-5555
 
For use in the book, fictitious names will be used for ALL STORIES submitted UNLESS you specify in the checkbox below. Please check box if you WOULD like your work credited to YOU, in your legal name as stated above. IF THE BOX IS LEFT UNMARKED THE SUBMISSION WILL BE ATTRIBUTED TO A FICTITIOUS NAME.
 


 


 
Please enter your submission in the box below. To assure that you don't lose your work in the eventuality of a network failure or some other issue, we recommend using a word processing application for extended passages then copy and pasting in to the box below.
 
 
 

Waiver of Liability

 
This is a legal document which affects your legal rights. (To be completed by anyone 13-17 and his or her parent or guardian; those 18 and over complete on their own) WE/I UNDERSTAND THAT BY CLICKING SUBMIT ON THE LILAREYNA.COM WEBSITE: THE MINOR AND PARENT/GUARDIAN VOLUNTARILY GIVES FULL CONSENT to Lila Reyna and organizers of the Empowerment event and/or Empowerment book, full editing and publishing rights of submitted material, including personal stories or original poems. THE MINOR AND PARENT OR GUARDIAN, WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the fault of the entities or persons released, or actions of any kind which may hereafter occur to participant including the publication of personal information. THE PARENT AND/OR GUARDIAN HEREBY AGREES TO INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons associated with Lila Reyna and/or Action Awareness Training from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by negligence of release or otherwise. THE MINOR AND PARENT/GUARDIAN HEREBY ASSUME ALL OF THE RISKS of participating and/or volunteering in this activity or event, including by way of example and not limitation, any damage that may arise from negligence or carelessness on the part of the persons or entities being released. WE/I ACKNOWLEDGE that this Consent for Release of Information and Waiver of Liability Form will be used by the event holders, sponsors, and organizers of the activity or event in which I may participate, and it will govern my actions and responsibilities in the Empowerment submission and publication event. BY CLICKING SUBMIT, THE PARENT OR GUARDIAN HAS READ AND AGREES TO THE RELEASE OF INFORMATION AND WAIVER OF LIABILITY AND DOES SO VOLUNTARILY AND WITH THE UNDERSTANDING THAT SUBSTANTIAL RIGHTS ARE BEING GIVEN UP. I/WE FURTHER ACKNOWLEDGE THAT FAILURE TO WITNESS THIS AGREEMENT SHALL NOT AFFECT ITS VALIDITY.
 

 
 
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Minor Release Form

If under the age of 18, you may download the Minor Release formhere
 
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