Fillable 2021 Congressional Art Competition (US House of Representatives)

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2021 Congressional Art Competition (US House of Representatives)

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2021 Congressional Art Competition
Student Information & Release Form
PLEASE COMPLETE THE RELEASE FORM ON PAGE 2. PAGE 1 OF 2
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:
STATE & DISTRICT:
STUDENT INFORMATION
NAME: ☐ Mr. ☐ Ms.
GRADE:
STREET ADDRESS:
CITY:
STATE:
ZIP:
MAILING ADDRESS (IF DIFFERENT):
STUDENT EMAIL:
STUDENT PHONE (CELL):
PARENT OR GUARDIAN NAME(S):
PARENT PHONE (HOME):
PARENT PHONE (WORK or CELL):
PARENT EMAIL:
STUDENT T-SHIRT SIZE:
SCHOOL
SCHOOL NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
ART TEACHER NAME:
ART TEACHER PHONE:
ART TEACHER EMAIL:
ART COMPETITION ENTRY
TITLE OF ENTRY:
MEDIUM:
DESCRIPTION:
Please include a detailed description of the artwork, clearly identifying the major elements of the piece.
For office use only:
FRAMED DIMENSIONS: Height:________ inches Width: _______inches Depth: ______ inches
See official guidelines for framed size and artwork weight restrictions.
2021 Congressional Art Competition
Student Information & Release Form
PAGE 2 OF 2
(CONTINUED FROM PAGE 1)
STUDENT NAME:
STATE & DISTRICT:
TITLE OF ENTRY:
ORIGINALITY CERTIFICATION
I hereby certify that, to the best of my knowledge, the art entry described above is an original work of authorship by the
undersigned student and that it is not copied from, nor does it include, any other person’s copyrighted work.
We recognize that many students may not be able to have their teacher sign the student release form due to school
closures. When submitting the form, the student may attach to the form an email from an art teacher certifying the
artwork's originality.
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. The undersigned grant the Member, the House, their employees and agents, the United States, and
the Congressional Institute, Inc., and its employees, the right to reproduce the art entry for any non-commercial purpose.
The undersigned further release the Member, the House, their employees and agents, the United States, and the
Congressional Institute, Inc., and its employees, 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, the United States, and the Congressional Institute, Inc., and
its employees, 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)
!
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2021 Congressional Art Competition (US House of Representatives)

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Completed 14 February 2021

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