The participant and parent or guardian certifies that the artwork submitted is original and not a copy or reproduction. Project S.N.A.P. reserves the right to select and use this submitted artwork in any mural created for Project S.N.A.P. Mosaic Mural programs. In addtion, Project S.N.A.P. has the right to change an image size or crop it, in order to make it suitable for use by Project S.N.A.P. The participant grants to Project S.N.A.P. and to Allegheny Health Network the right to use this submitted artwork, without limitation, for any purpose (including commercial applications).

In connection with my/my child’s participation in the Project S.N.A.P. artwork collection, I hereby authorize the disclosure of my/my child’s information collected on this Artwork Entry Form, which includes the artwork and any related message. Allegheny Health Network may release my/my child’s information collected hereunder to Project S.N.A.P in connection with the Project S.N.A.P. artwork collection, for use in the Project S.N.A.P. Mosaic Mural program, including but not limited to the Project S.N.A.P. Online Art Museum and email communication about the Project S.N.A.P. program. I understand that once this information is disclosed to Project S.N.A.P. that it may not be covered by federal privacy regulations and that the information collected on this Artwork Entry Form may be redisclosed and no longer protected by the federal privacy regulations. As described in the Notice of Privacy Practices of Allegheny Health Network, I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by Allegheny Health Network or Project S.NA.P. in reliance on this authorization, by sending a written revocation to Allegheny Health Network, 120 Fifth Avenue, Suite 2900, Pittsburgh, PA 15222. This authorization will not expire, unless revoked as described in the preceding sentence. I understand that I am not required to sign this Artwork Collection Form and that Allegheny Health Network will not condition the provision of any treatment to me/my child on my signing of this form.

Allegheny Health Network and Project S.N.A.P. respect the privacy of all mosaic mural project participants. The above personal data will not be shared with any outside organizations.