Artwork Submission Form - Children’s Radon Poster Contest
Important Note to Teachers: Please fill in (type or print) the requested information under “Teacher" before making copies of this form for your
students. Please ask your students and their parent/guardian to clearly print their information.
Teacher
Date
Name
Name of School
Phone Number
Address
City
State
Zip
State
Zip
Student
Name
Grade
Address
Age
City
Title of Artwork
Check your topic:
What is radon?
Radon can cause lung cancer
Where is radon found?
Test your home for radon
Where does radon come from?
Other radon messages
Format for entries: Paper guidelines 12 x 18 and 8.5 x 11 sizes are preferred, but all submission sizes will be accepted
Parent/Guardian
I give my consent to the New York State Department of Health to use my minor child’s art, talent, name, school, likeness, and entry in the Department’s student art shows, for
publications, for promotional purposes, for website documentation, and for media press releases. All copyrights of artwork shall reside with the entering artist. I understand that
neither my minor child nor I will receive compensation for the use of this likeness or for exhibition of this artwork for the purpose of promoting radon safety to New Yorkers. I
understand that care will be taken in handling this artwork, but I will not hold the Department responsible for loss or damage to this artwork.
Name
Phone Number
Address (if different from student)
City
Signature
State
Zip
Date
No entries can be accepted without this completed form.
Mail posters to: NYSDOH Radon Program, ATTN: Poster Contest, Bureau of Environmental Radiation Protection, Corning Tower Room 1218,
Empire State Plaza, Albany, NY 12237.
Radon Program contact info: (518) 402-7556 (phone), (518) 402-7554 (fax), [email protected] (email)
Please tape this form to the back of the poster
3/17