2007 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:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TITILE 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'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
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 releases 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's Signature and Date