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 Medium     Braille Medium

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. Entry also implies permission to photograph the artist for publicity purposes during the fall award ceremony in Louisville.