[*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***Student Information/Release Form**
*(**One entry permitted per student**)\_\_\_\_ *]{.underline}

MEMBER: [Representative Chris Van Hollen
(MD-08)]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_STATE: [Maryland
(MD)\_\_\_\_\_\_]{.underline}

Note: This information is used for program certificates. Please
**print** & make sure the form is complete.

STUDENT'S NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
GRADE: \_\_\_\_\_\_\_\_\_

Pronunciation of
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sex:\_\_\_\_\_\_\_\_\_\_\_

STUDENT E-MAIL
ADDRESS:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME OF PARENT OR GUARDIAN:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

HOME ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CITY: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP:
\_\_\_\_\_\_\_\_\_\_\_\_\_

PHONE: (HOME)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (ALTERNATE
#) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SCHOOL:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ART TEACHER: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SCHOOL ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ART TEACHER PHONE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-MAIL:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TITLE OF ENTRY:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

MEDIUM: (Be Specific)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FRAMED
DIMENSIONS:\_\_\_\_\_\_\_\_\_

(Must be no larger than 30"x30"x4" including frame)

> **Originality Certification**

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

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Teacher's Signature and Date Student's Signature and Date

**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 to the Member
and the House the right to include or authorize the inclusion of the art
entry in a compilation or derivative work in any form, including, but
not limited to, book, pamphlet, website, or electronic format, for the
benefit of the Member, the House, or the United States. The undersigned
hereby release 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. Notwithstanding the grants of the
rights above, the undersigned retain all rights, including, but not
limited to, legal title and copyright, in the art entry during and
subsequent to the Art Competition. The undersigned further agree 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..

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Parent/Guardian's Signature and Date Student's Signature and Date