ArtWorks - Performance Piece Submission

Artist Info:
Hospital Affiliation*
Your Child Life Specialist's Name*
Child Life Specialist Email Address*
Performer Name*
First Last
Type of Participant*
- Patient
- Sibling
- Other
Mailing Address*
Street Address Apt., Floor, Suite # City State / Province / Region ZIP / Postal Code
Phone Number*
Email Address*
Current Age*
Please enter a number from 1 to 99.
Date of Birth*
MM slash DD slash YYYY
Please attach a photograph of yourself to accompany your work at Express Yourself! (Optional)
Max. file size: 4 MB.

ArtWorks Release Form
The undersigned hereby authorizes ArtWorks, The Naomi Cohain Foundation, Inc. (“ArtWorks”) to use the name, age, healthcare agency affiliation, and likeness of the participant identified below (“Participant”), including but not limited to images as may be captured in photographs, videos, audio, artwork, quotes, and any other material or information provided by or on behalf of Participant, or created by Participant, in connection with ArtWorks’ programs. Participant hereby releases ArtWorks and any affiliated or related persons or entities from any and all claims and causes of action based upon ArtWorks’ use of the materials. Participant grants ArtWorks permission to use, publish, exhibit and/or reproduce the materials in any manner and in any and all media now known or later developed, without obligation to pay participant any royalty or compensation of any kind. Such rights include but are not limited to use in connection with advertising, social media, publicity, marketing, fundraising, promotional and other commercial purposes. ArtWorks is not liable for any photographs, videos, artwork, and/ or any other material or information provided by or on behalf of Participant taken and/or published by any third party. Participant also grants ArtWorks a perpetual, royalty free, irrevocable, transferable license to any art, writings, or other authorship created by Participant in connection with any ArtWorks program. Such license includes but is not limited to: (i) copyrights; (ii) rights to reproduce, display, perform, sell and distribute the artwork or copies thereof, in whole or in part, in any form or medium whatsoever; (iii) moral rights, rights to decide whether and in what manner the artwork shall be published, advertised, publicized, performed or exploited; (iv) rights to create derivative artwork and alter, expand, adapt, modify and make any arrangements of the artwork; and (v) all rights to enforce, and to seek and secure any statutory protections, as to the artwork, including the collection of damages. The foregoing grant shall be limited to those uses which ArtWorks believes, in its sole and absolute discretion, will further ArtWorks’ mission and purpose. Participant hereby releases ArtWorks from all claims, demands and liabilities whatsoever in connection with the foregoing.
Please select one*
- These terms and conditions create a contract between you and ArtWorks (ArtWorks Release Form). By checking this box, you are confirming your understanding and acceptance of the ArtWorks Release Form. The undersigned certifies that he/she does agree to its terms on behalf of him/herself and/or his/her minor child. The rights granted herein are granted in consideration of participant’s involvement in ArtWorks’ programs and acknowledge that such participation would not be possible without the release and license granted herein.
Parent/Guardian Name*
First Last
Parent/Guardian Signature*
(Parent/Guardian must sign for a child 18 and under. If participant is over 18, he/she may sign)
Date*
MM slash DD slash YYYY
Questions: Daniela Verdugo, Program and Communications Manager

ArtWorks, The Naomi Cohain Foundation
96 Engle Street, Suite 120
Englewood, NJ 07631
Phone: 201-608-0146
Fax: 201-608-0148
dani@artworksfoundation.org
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ArtWorks – Performance Piece Submission

Step 1 of 3

Artist Info:

Performance Info:

ArtWorks Release Form