**2008 Congressional Art Competition**

**Student Information/ Release Form**

MEMBER:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
STATE: \_\_\_\_\_\_\_\_\_\_\_

Note: This information is used for program certificates. Please make
sure the form is complete and correct.

ART STUDENT NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
GRADE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

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

PHONE: (HOME)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (WORK)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

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

ART TEACHER PHONE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

Student
email:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
T-Shirt Size\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Originality Certification**

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

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

Teacher Signature and Date Student 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 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.

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

Parent/Guardian Signature and Date Student Signature and Date