HJClix Request for Access
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 507-523-2073.
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: (optional) ________________________________________________________________
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: ______________________________________________________
Revision 5.12.2009