Artist Authorization and Release Form

LeadingAge New York’s 2017 Art Competition and Exhibit will involve the display of chosen artwork at
several locations across the state, as well as in the LeadingAge New York offices in Latham and on the LeadingAge NY
website and its social media pages (e.g., Facebook and similar sites). LeadingAge New York staff will take all possible
precautions in transporting these works to the exhibit sites across the state; however, LeadingAge NY is not responsible
for loss or damage of artwork.

An Authorization/Release form must be filled out for each painting being submitted.

Please print clearly or type.

I, ___________________________________________, hereby give permission to LeadingAge New York to

display my artwork, entitled _____________________________________________ , as part of its 2017 Art
Competition and Exhibit, in the LeadingAge New York offices, at other locations in New York State, on the
LeadingAge New York website, its social media sites and its Daily News Clips. I also give LeadingAge New York
permission to use my prefix (Mr. Ms.) and first letter of my last name and place of residence. Check the box below
to give us permission to use part of the information from the attached biography form, in promoting
LeadingAge New York and the 2017 Art Competition and Exhibit.

I understand that LeadingAge New York will make every effort to protect my work and to return it to me when the
exhibit has concluded, but that LeadingAge New York cannot be held responsible for loss or damage of the work.

I understand that I may refuse to sign this release and that my refusal to sign will not affect my ability to obtain
services from my facility or program. However, if I refuse to sign this release, my artwork will not be included in
the LeadingAge New York 2017 Art Competition and Exhibit.

Check here if you give LeadingAge New York permission to use part of your biography information.


Date: ______________________________________________________________________________
Facility:____________________________________________________________________________
Address: ___________________________________________________________________________
City/Town: __________________________________________________________________________

* Signature:__________________________________________________________________________

* If artist is unable to sign, signature of authorized person, including title and address:

Name/title:___________________________________________________________________________

Address:_____________________________________________________________________________

City/Town: __________________________________________________________________________

Signature:____________________________________________________________________________

This form may be copied.

Please return this form with your artwork to: Earl Gifford, LeadingAge New York, 13 British
American Blvd., Suite 2, Latham, N.Y. 12110