APH InSights 2003 Entry Form A

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APH InSights 2003 Entry Form A

Form A is for Preschool through High School Artists (Adults Use Form B) Click here for Form A in PDF format.

Deadline for entry is April 1, 2003.

Complete this form and then print two copies to be sent with your entry. A completed entry form and one copy of the form must accompany the artwork. All applicable information MUST be completed, or the entry may be disqualified.

Mail your application package to:
APH InSights
American Printing House for the Blind, Inc.
1839 Frankfort Ave.
Louisville, Kentucky 40206-3152

Name of Student Artist:
Home Address:
City:
State: Zip or Postal Code:
Parent's Daytime Phone with Area Code:
E-mail:

Visual Acuity: Must meet the legal definition of blindness (see "Eligibility" section of the rules). Do not list eye diseases. List a doctor's measurement of your vision. List your corrected visual acuity with glasses or other lens:
Right Eye:
Left Eye:
Or list restricted visual field (percent):

Call 1-800-223-1839, ext. 357 with questions on how to list visual acuity.

Your age at the onset of your blindness?
Your age now?

This entry is sent from:
School Home

Where should we return art and send correspondence?
School Home

Which reading medium do you prefer for correspondence?
Print Braille

School Name:
School Address:
City:
State: Zip or Postal Code:
Teacher's Name:
School Phone with Area Code:
Fax with Area Code:
E-mail:

Date your school year closes for summer:
Month: Day:

Indicate your grade placement: Preschool, Kindergarten, 1, 2, 3, etc., Ungraded (multiple impairments)

Title of Artwork:
Art Medium/Media:
Value in U.S. dollars (Must be included or work will not be insured.):

Do you want to sell your art?
Yes No

(If yes, your work will be offered for sale at the value listed, plus a 10% handling fee that APH will retain.)

Release: Entry to APH InSights implies permission for APH to reproduce artwork, to retain artwork for up to one year for display purposes, and to publicize the artist by releasing any information provided on the entry form.