YAM 2018 PAEA Artwork Permission Request/Release
Consent Statement:
By this signature, I shall hold harmless the Commonwealth of Pennsylvania, its agencies and employees, and PAEA its agents or
employees from any and all liability in the acquisition, storage, transportation, or exhibition of this work of art. I hereby grant to the Pennsylvania Department of Education (PDE) and PAEA YAM Committee permission to display in the news media or electronically via the Internet or in other displays, the art work (described in this form) submitted by my child in conjunction with his/her participation in the 2018 PAEA Youth Art Month Exhibition. By signing this release, I consent that my child’s artwork, name, grade, and school district may be displayed by PDE and/or PAEA, allowing this information to be viewed by the general public. I also grant the PDE and PAEA permission to display in the news media or electronically via the Internet and in other displays, photographs and/or video footage of my child taken in conjunction with his/her participation in the student art exhibition.I hereby give the Pennsylvania Art Education Association (PAEA) the absolute right and permission, in regard to my artwork. I hereby release and discharge the Pennsylvania Art Education Association from any and all claims and
demands arising out of or in connection with the use of the artwork. I have read the foregoing and fully understand the contents thereof.

If under age 16, adult signature required:
I represent that I am the (father, mother, guardian) of the above named child. I hereby consent to the foregoing on his/her behalf.

Date *
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DD
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YYYY
Artist's Last Name *
Your answer
Artist's Age As of 2/26/2018 *
Your answer
Artist's First Name *
Your answer
Title of Work *
Your answer
Address *
Your answer
Artist's eSignature *
Your answer
Parent's eSignature *
Required if student is under age 16, Artists over age 16 may sign for themselves.
Your answer
Parent email address *
Your answer
School Name *
Your answer
Your Art Teacher's Name *
Your answer
Your Art Teacher's Email Address *
Your answer
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