Student Information
Salutation: *
Mr. Ms.
First Name: *
Last Name: *
Grade: *
Street Address: *
City: *
State:
Zip Code: *
Mailing Address: (if different)
Email: *
Cellphone: *

Name of Hometown Newspaper:
Is it ok to use your name, parent/guardian names and high school in a press release? *
Yes No
Parent/Guardian Information
Names of Parents/Guardians: *
Parent Email Address: *
Parent Home Phone: *

Parent Work Phone or Cellphone:

School Information
High School Name: *
High School Address:
City: *
State: *
Zip Code: *
Art Teacher Name: *
Art Teacher Phone Number: *
Art Teacher Email: *
Art Competition Entries
Number of Entries:

Art Competition Entry One
Entry Title: *
Entry Medium: *
Description: *

Please include a detailed description of the artwork, clearly identifying the major elements of the piece.
Art Competition Entry Two
Entry Title: *
Entry Medium: *
Description: *

Please include a detailed description of the artwork, clearly identifying the major elements of the piece.
Originality Certification
I hereby certify that, to the text of my knowledge, the art entry described above is an original work of authorship by the student listed above and that it is not copied from, nor does it include, any other person's copyrighted work. *
Artwork Release
I/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's Full Name: *


Is the student under the age of 18? *
Yes No

Parent/Guardian Full Name: (if student is under 18) *


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