Form Center

2. First Name
3. Last Name
5. Artist Name (If other than above)
7. Email Address
8. Phone Number
10. Address1
12. Address2
14. City
15. State
16. Zip
18. How did you hear about this Call to Artists?
20. Artist Bio
22. Website
23. Facebook
25. Instagram
26. Twitter
28. Submission File (Upload Image)*
29. Title of Submission*
31. Description of Submission *
33. Submit Artist Headshot

    Upload photo of artist, if available.

35. CALL TO ARTISTS SUBMISSION CONSENT, WAIVER AND RELEASE FORM
    
    This consent, waiver and release form must be submitted with each separate design. A separate form must also be submitted for each person who contributes to the design. By submitting a design to the City of Mount Dora, you are agreeing to abide by the Rules and Regulations of the 2023 Painted Asphalt Crosswalk Call to Artists and that winning entries will be selected by a panel of judges, whose decision is final. 

37. I, (name)*

39. (for myself or my minor child) hereby submit the design identified as:

41. Submission Title*

43. (Design) to the City of Mount Dora (City) for consideration in the 2023 Painted Asphalt Crosswalk Call to Artists. I hereby swear, affirm or certify that I am (or my minor child is) the sole creator or a joint creator of the Design. I agree that if the Design is selected as a winning submission, I, on my own behalf and on behalf of my heirs, representatives, executors, assigns, administrators or any other person acting on my behalf or on behalf of my estate, hereby grant the City permission to use all or part of the Design for any other purpose that the City deems appropriate. I hereby irrevocably authorize the City, or an authorized agent thereof, to edit, alter, copy, exhibit, publish and/or distribute the winning Design for any and all lawful purposes. In addition, I waive any right to inspect or approve the finished product wherein the winning Design appears. Additionally, I waive any right to royalties or other compensation arising out of or related to the City’s use of the winning Design beyond the initial cash prize.

45. I (name)*

47. , hereby grant the City the right to use my name, photograph, statements, quotes and testimonials or the name, photograph, statements, quotes and testimonials of my minor child,  

49. (name of minor child, if applicable)

51. , in relation to the Design, regardless of whether the Design is chosen as the winning Design, for any lawful purposes without notification or compensation. I specifically acknowledge and understand that the City maintains the right to reproduce, reprint, distribute, display or exhibit the Design, if selected as a winning design(s), for advertising, publicity and promotional purposes on its website, social media, television, radio, newspaper, magazine or other media outlets.

    I hereby swear, affirm or certify that the Design is an original work and does not violate copyright laws or infringe upon the intellectual property rights of another. I hereby agree to indemnify and hold the City harmless from any claims of copyright infringement or any other claims of third party related to or in any way associated with the Design. 

    I understand that the original Design is still my property and I may take any steps necessary to legally protect my ownership interest, after the Call to Artists has concluded, including copyrighting the design or I may otherwise use the original of the Design as I deem appropriate, so long as the same is not used in a manner that would be considered adverse to the image of the City or would in any way interfere with the City’s rights to utilize the design as it deems appropriate. I understand that this means that I may maintain ownership of the Design or sell, grant, gift or otherwise transfer ownership of the Design so long as the new owner agrees to the City’s right to utilize the Design free of interference.

53. Electronic Signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
55. Submitter Full Name*
56. Submitter Date of Birth*
58. Type Name Below to Indicate Submitter Signature*
59. Signature Date*
61. Parent/Legal Guardian Full Name

    (If submitter is under the age of 18)

63. Parent/Legal Guardian Signature

    (If submitter is under the age of 18)

64. Signature Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field