Last Name:

Telephone:

Email:

(Please provide at least one of telephone or email, so we have some way to contact you.)

Title of artwork/contribution:

 I agree for this piece of work to be sold in aid of Haiti. All proceeds from the sale will be sent via the Disasters Emergency Committee. The Hastings 4 Haiti organisers will make all efforts to keep your artwork or contribution safe until the sale, but we cannot be responsible for any loss or damage.