Please PRINT clearly. This information is used for certificates and
awarding scholarships.

Incomplete forms will not be accepted.

+-----------------------------------+-------------------+--------------+
| **MEMBER/DISTRICT INFORMATION**   |                   |              |
+-----------------------------------+-------------------+--------------+
| MEMBER OF CONGRESS NAME: Denny    |                   | STATE: MT-00 |
| Rehberg                           |                   |              |
+-----------------------------------+-------------------+--------------+
|                                   |                   |              |
+-----------------------------------+-------------------+--------------+
| **STUDENT INFORMATION**           |                   |              |
+-----------------------------------+-------------------+--------------+
| NAME:                             |                   | GRADE:       |
+-----------------------------------+-------------------+--------------+
| STREET ADDRESS:                   |                   |              |
+-----------------------------------+-------------------+--------------+
| CITY:                             | STATE:            | ZIP:         |
+-----------------------------------+-------------------+--------------+
| STUDENT EMAIL:                    |                   |              |
+-----------------------------------+-------------------+--------------+
| T-SHIRT SIZE:                     |                   |              |
+-----------------------------------+-------------------+--------------+
| PARENT OR GUARDIAN NAME(S):       |                   |              |
+-----------------------------------+-------------------+--------------+
| PARENT PHONE:                     | PARENT WORK       |              |
|                                   | PHONE:            |              |
+-----------------------------------+-------------------+--------------+
|                                   |                   |              |
+-----------------------------------+-------------------+--------------+
| **SCHOOL**                        |                   |              |
+-----------------------------------+-------------------+--------------+
| SCHOOL NAME:                      |                   |              |
+-----------------------------------+-------------------+--------------+
| STREET ADDRESS:                   |                   |              |
+-----------------------------------+-------------------+--------------+
| CITY:                             | STATE:            | ZIP:         |
+-----------------------------------+-------------------+--------------+
| ART TEACHER NAME:                 |                   |              |
+-----------------------------------+-------------------+--------------+
|                                   |                   |              |
+-----------------------------------+-------------------+--------------+
| **ART COMPETITION ENTRY**         |                   |              |
+-----------------------------------+-------------------+--------------+
| TITLE OF ENTRY:                   |                   |              |
+-----------------------------------+-------------------+--------------+
| MEDIUM:                           |                   |              |
+-----------------------------------+-------------------+--------------+
| DESCRIPTION:                      |                   |              |
+-----------------------------------+-------------------+--------------+
| FRAMED DIMENSIONS:                |                   |              |
| Height:\_\_\_\_\_\_\_\_ inches    |                   |              |
| Width: \_\_\_\_\_\_\_inches       |                   |              |
| Depth: \_\_\_\_\_\_ inches        |                   |              |
|                                   |                   |              |
| See official guidelines for       |                   |              |
| framed size and artwork weight    |                   |              |
| restrictions.                     |                   |              |
+-----------------------------------+-------------------+--------------+

PAGE 1 OF 2

PLEASE COMPLETE THE RELEASE FORM ON PAGE 2.

  ----------------------------------- -------------------- ---------------
  **(CONTINUED FROM PAGE 1)**                              

  STUDENT NAME:                                            STATE:

  TITLE OF ENTRY:                                          

                                                           

  **ORIGINALITY CERTIFICATION**                            

  I hereby certify that, to the best                       
  of my knowledge, the art entry                           
  described above is an original work                      
  or authorship by the undersigned                         
  student and that it is not copied                        
  from, nor does it include, any                           
  other person's copyrighted work.                         

  STUDENT SIGNATURE                   ART TEACHER          
                                      SIGNATURE            

                                                           

  **ARTWORK RELEASE**                                      

  We, the undersigned, represent that                      
  the art entry described above is an                      
  original work of authorship                              
  personally created by the                                
  undersigned student to which the                         
  student is entitled copyright                            
  protection. In consideration for                         
  the acceptance of the art entry by                       
  the Member of Congress designated                        
  above in *An Artistic Discovery*                         
  (the Congressional Art Competition                       
  sponsored by the U.S. House of                           
  Representatives) and intending to                        
  be legally bound hereby, the                             
  undersigned grant the Member and                         
  the House the right to publicly                          
  display the art entry, if it is                          
  selected for display, in accordance                      
  with the rules of the Art                                
  Competition, for a period of two                         
  years from the latest date on this                       
  form. The undersigned acknowledge                        
  that the final decision regarding                        
  the suitability of an art entry to                       
  be displayed in the Capitol will be                      
  made by a House panel chaired by                         
  the Architect of the Capitol. The                        
  undersigned also grant the Member,                       
  the House, their employees and                           
  agents, and the United States the                        
  right to reproduce the art entry                         
  for any non- commercial purpose.                         
  The undersigned further grant the                        
  Member, the House, their employees                       
  and agents, and the United States                        
  from any and all liability for                           
  damage, loss, or misappropriation                        
  of the art entry during and                              
  subsequent to the Art Competition.                       
  The undersigned further agrees to                        
  indemnify, hold harmless and defend                      
  the Member, the House, their                             
  employees and agents, and the                            
  United States against any and all                        
  claims of any nature whatsoever,                         
  including, but not limited to,                           
  claims of copyright infringement,                        
  by any party whatsoever, arising                         
  out of or in any way related to the                      
  submission of the art entry in the                       
  Art Competition.                                         

  STUDENT SIGNATURE                   PARENT/GUARDIAN      
                                      SIGNATURE (IF UNDER  
                                      18)                  

                                                           
  ----------------------------------- -------------------- ---------------

PAGE 2 OF 2