HJClix Request for Access
Access information for HJClix may not be available for up to 14 days after your
student’s picture day.
Download this form - (PDF format)
To provide protection of your private data, including your image, Herff Jones, Inc. asks that
you fill out the information requested below prior to ordering portraits. Please do not ask
Herff Jones employees for information to complete this form.
The following information must be entirely filled out by the subject or their legal guardian.
When complete, please fax to HJClix Customer Service at 704-845-2779 or mail to:
P.O. Box 1013
Charlotte, NC 28201-1013
*Please allow 2 business days for access information.
Date Photographed: _______________________
Subject Information
Subject Name: _______________________________________________________________
Subject Address: _____________________________________________________________
School Name: ________________________________________________________________
School Address: ______________________________________________________________
Teacher/Coach Name: ____________________________ Grade/Event: _________________
Legal Guardian Information
Guardian Name: ______________________________________________________________
Day Phone: _____________________________Evening Phone: ________________________
Guardian Address: ____________________________________________________________
Shipping Address, if different: ___________________________________________________
Relationship to Subject: ________________________________________________________
Email address: _______________________________________________________________
I certify that I am 18 years of age or older, or the legal guardian of the above named subject.
I will indemnify, defend, and hold harmless Herff Jones, Inc., its affiliated companies,
directors, officers, employees, and representatives from any claim or demand (including costs,
expenses, and reasonable attorneys fees) arising out of or relating to printing or delivering
these portraits.
Date: _______________________
Subject or legal guardian’s printed name: __________________________________________
Subject or legal guardian’s signature: _____________________________________________
*Again, please allow 2 business days for access information.
Rev 12.9.11