Office of Congresswoman Liz Cheney

Congressional Art Competition Form

Name: [required-name] – [required-grade] Grade
Street Address: [required-address], [address2]
City, State Zip Code: [required-city], [required-state] [required-zip]
Student Email: [required-valid-email] | Student Phone: [required-student-phone]
T-Shirt Size: [required-tshirt-size]
Parent Name(s): [required-parents]
Parent Home Phone: [required-parent-home-phone] | Parent Work/Cell Phone: [required-parent-cell-phone]

School Information

Name of High School: [required-highschool]
Address: [required-hs-address]
City, State Zip Code: [required-hs-city], [required-hs-state] [required-hs-zip]
Art Teacher Name: [required-teacher]
Art Teacher Phone: [required-teacher-phone] | Art Teacher Email: [required-teacher-email]

Entry Information

Title: [required-entry-title]
Medium: [required-medium]
Description: [required-description]

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.

Artist’s Signature: ________________________________________

Art Teacher’s 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, 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, the United States, and the Congressional Institute, Inc., and its employees, the right to reproduce the art entry for any noncommercial 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.

Artist’s Signature: ____________________________________________

Parent/Guardian’s Signature: ___________________________________

Date: ______________________________________________________

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